The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2009
2012
U.S. Bank Retiree Health Care Program
Summary Plan Description
Effective January 1, 2012
HR1201K (10/2011)
IMS H000097853

Retiree Health Care SPD Effective January 1, 2012
Dear Retiree:
U.S. Bank is pleased to offer health care coverage for eligible retirees and their eligible dependents.
The material in this summary plan description (SPD) summarizes the current terms of the U.S. Bank
Retiree Health Care Program.
Our philosophy about health care benefits is the same for retirees as it is for our active employees.
We create our programs to provide cost-effective, quality benefits. To help moderate premium
increases due to rising health care costs, we continue to modify plan features and diligently pursue
efforts to control both retiree and company costs as much as possible. We encourage you to be an
informed consumer and take time to understand these benefits so that you may make good health
care decisions for you and your family. Please read this material carefully.
Also, it is important for you to be fully informed about Medicare. Your State Health Insurance
Assistance Program can tell you how to get more information, or you may access Medicare
information online at www.medicare.gov. You may also wish to access the American Association for
Retired Persons (AARP) Web site at www.aarp.org.
Beginning January 1, 2006, the Medicare Part D prescription drug benefit became available to
retirees that are Medicare eligible. Because prescription drug coverage will continue to be primary
(except for prescription drugs covered under Medicare Parts A or B) under U.S. Bank’s Retiree
Health Care Program, we strongly recommend THAT YOU DO NOT ENROLL IN MEDICARE
PART D. More information is included in the “How Coverage Works If You Are Age 65 Or Older
Or Pre-65 And Medicare Eligible” section of this SPD. If you do enroll in Medicare Part D coverage,
you will no longer receive prescription drug coverage under the Retiree Health Care Program, and
your monthly Retiree Health Care Program premium will not be reduced. Your monthly premium
covers both medical and pharmacy benefits, and it will not be changed. If you decide to enroll in
Medicare Part D, you will pay additional unnecessary premiums, as you will be paying a premium
for both Medicare Part D and the Retiree Health Care Program. Please Note: If you are enrolled in
the UHC PPO option, Medicare will cancel your UHC PPO coverage if you enroll in Medicare
Part D. Once Medicare cancels your UHC PPO coverage you will no longer be enrolled in the
U.S. Bank Retiree Health Care Program.
Please also keep in mind that U.S. Bank offers Retirement Counselors to help you make the most of
your retirement. Counselors are professionally trained on the benefits offered to retirees of U.S. Bank
and provide one-on-one assistance. There is no cost to you for a consultation(s). Just call 1-800-806-
7009 and ask to speak to a Retirement Counselor. Retirement Counselors are available between 8
a.m. and 5 p.m. CT, Monday through Friday.
Please keep this SPD handy for future reference. If you have questions about any information in the
SPD, please call the appropriate number listed in the “Important Resources” section of this SPD.
Sincerely,
Ellen M. Peterson
Senior Vice President, Human Resources
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Retiree Health Care SPD Effective January 1, 2012
Table of Contents
Eligibility and Enrollment ........................................................................................7
Eligibility and Enrollment Rules ...............................................................................................................................7
Additional Eligibility and Enrollment Information .................................................................................................12
Retiree Health Care Options ..................................................................................16
Your Health Care Options — Retirees Under Age 65 and non-Medicare Eligible .................................................16
Your Health Care Options — Retirees Age 65 or Older or Pre-65 and Medicare Eligible .....................................19
Pre-Existing Conditions Limitations .......................................................................................................................21
How to Show Previous Creditable Coverage...........................................................................................................22
Wellness ..................................................................................................................................................................23
Deductibles, Coinsurance and Maximums............................................................24
Deductibles..............................................................................................................................................................24
Copayments and Coinsurance..................................................................................................................................26
Out-of-Pocket Maximum.........................................................................................................................................26
Health Care Options Summary..............................................................................28
What the Options Cover .........................................................................................30
Early Retiree Medical Option..................................................................................................................................30
Comprehensive Option ............................................................................................................................................38
How Coverage Works if You Are Under Age 65 and Not Medicare Eligible....46
Which Network Providers to Use ............................................................................................................................46
Allowed Amounts....................................................................................................................................................48
Transition of Care....................................................................................................................................................50
Preadmission Notification and Prior Authorization for BCBS of MN-Administered Benefits ...............................51
When You Have Other Coverage – BCBS of MN ..................................................................................................54
Liability of Another Party: When Another Person is Responsible for Your Covered Health Care Expenses.........55
What Happens When You or a Dependent Turn Age 65 or Become Medicare Eligible Before Age 65.................56
Medicare Eligible Retirees and Dependents Turning Age 65 .............................57
What Happens When You Turn Age 65 or Become Medicare Eligible before Age 65 ..........................................57
What Happens When a Dependent Turns Age 65 or becomes Medicare Eligible Before Age 65 ..........................57
Preadmission Notification and Prior Authorization.................................................................................................58
Your Benefit Option Integration With Medicare.....................................................................................................58
Claiming Health Care Benefits with Medicare........................................................................................................59
How Coverage Works If You Are Age 65 or Older or Pre-65 and Medicare
eligible .......................................................................................................................60
Your Benefit Option If You are Medicare Eligible .................................................................................................60
Your Prescription Drug Coverage under the Program and Medicare Part D...........................................................61
Pharmacy..................................................................................................................63
Pharmacy Deductibles, Coinsurance and Maximums..............................................................................................63
Pharmacy Coverage Summary ................................................................................................................................66
Formulary Drugs......................................................................................................................................................68
Diabetic Supply Exception ......................................................................................................................................69
Mail Order Maintenance Drug Provision ................................................................................................................69
Specialty Drug Provision.........................................................................................................................................70
Medco’s –Mail Order Service Pharmacy.................................................................................................................71
Education and Safety...............................................................................................................................................75
Retail Pharmacy.......................................................................................................................................................75
Prior Authorization for Pharmacy Coverage ...........................................................................................................76
Step Therapy............................................................................................................................................................77
Additional Pharmacy Benefit Limitations ...............................................................................................................79
Infertility Coverage Maximum ................................................................................................................................79
Vaccines Covered by Medicare Part D....................................................................................................................80
Drugs Not Covered..................................................................................................................................................80
Filing Pharmacy Claims – Medco ...........................................................................................................................80
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Retiree Health Care SPD Effective January 1, 2012
When You Have Other Coverage – Medco .............................................................................................................81
When You Have Other Coverage – Medicare Part B Program ...............................................................................81
Health Management Program..................................................................................................................................82
BCBS of MN Options – General Information ......................................................83
Your ID Card...........................................................................................................................................................83
Bariatric Surgery......................................................................................................................................................83
Cardiac Care ............................................................................................................................................................84
Complex and Rare Cancers .....................................................................................................................................84
Emergency Care ......................................................................................................................................................85
Knee and Hip Replacements....................................................................................................................................85
Inpatient Maternity Care..........................................................................................................................................86
Mental Health and Substance Abuse Coverage.......................................................................................................87
Preventive Care........................................................................................................................................................88
Spine Surgery ..........................................................................................................................................................96
The Women’s Health and Cancer Rights Act of 1998.............................................................................................96
Transplants ..............................................................................................................................................................97
Non-Custodial and Full-Time Student Dependents Under the Early Retiree Medical Option ................................97
Filing Health Care Claims - BCBS..........................................................................................................................98
Allowed Amounts....................................................................................................................................................98
Eligible Health Care Professionals ........................................................................................................................100
Eligible Facilities...................................................................................................................................................101
General Exclusions................................................................................................................................................102
Using Your ID Card When Traveling....................................................................................................................107
Address Changes ...................................................................................................................................................107
Filing Claim Disputes ............................................................................................110
Eligibility and Enrollment Claims for All Options................................................................................................110
Release of Medical Records and Medical Reviews...............................................................................................110
Internal ERISA Claims Procedures .......................................................................................................................111
Request for Review of Adverse Benefit Determinations.......................................................................................113
Determination Upon Request for Review..............................................................................................................114
External Appeal Process........................................................................................................................................115
General Rules for Internal and External Claims ....................................................................................................118
Exhaustion of Administrative Remedies ...............................................................................................................118
Time Limitations for Commencing a Claim..........................................................................................................119
Time Limitations for Commencing a Legal Action...............................................................................................119
Venue for Legal Action .........................................................................................................................................119
Applicable Law for Legal Action ..........................................................................................................................119
Cost of Retiree Health Care Coverage ................................................................120
Retiree Health Care Credits...................................................................................................................................120
Eligibility for Retiree Health Care Credits ............................................................................................................120
Accumulating Retiree Health Care Credits............................................................................................................120
Nature of Retiree Health Care Credits and Reservation of Rights to Change Credits...........................................121
Interest on Retiree Health Care Credits .................................................................................................................121
Long-Term Disabilities and Retiree Health Care Credits......................................................................................122
Severance and Retiree Health Care Credits...........................................................................................................122
U.S. Citizens Working Overseas Do Not Earn Credits..........................................................................................122
Paying for Retiree Health Care Coverage with Credits .........................................................................................122
If You Die with Accumulated Credits ...................................................................................................................123
Special Transition Rules........................................................................................................................................123
Benefits Administrative Information...................................................................126
When Coverage Ends ............................................................................................................................................126
Failure to Notify U.S. Bank of Dependent Ineligibility.........................................................................................126
USERRA ...............................................................................................................................................................127
Situations That Affect Your Coverage ..................................................................................................................127
Health Coverage Certificates.................................................................................................................................127
Dependents Continuing Coverage After It Would Otherwise End — COBRA ....................................................127
Important Facts About Your Program ...................................................................................................................130
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Retiree Health Care SPD Effective January 1, 2012
Plan Administrator and Plan Sponsor....................................................................................................................133
Claims Administrator Information.........................................................................................................................134
Plan Year ...............................................................................................................................................................136
Questions About the Program................................................................................................................................136
VEBAs and Plan Trustee.......................................................................................................................................136
ERISA – Your Rights as a Member of the Program..............................................................................................136
HIPAA Privacy......................................................................................................................................................138
Glossary of Terms..................................................................................................143
Important Resources .............................................................................................152
Appendix.................................................................................................................154
Eligibility and Enrollment Rules Section A...........................................................................................................155
Eligibility and Enrollment Rules Section B...........................................................................................................161
Eligibility and Enrollment Rules Section C...........................................................................................................167
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Retiree Health Care SPD Effective January 1, 2012
This is the summary plan description (SPD) for the U.S. Bank Retiree Health Care Program and
the U.S. Bank Wellness Program, components of the U.S. Bank Benefits Program. Please read
the information carefully and file it with your benefits materials.
U.S. Bank has established the U.S. Bank Comprehensive Welfare Benefit Plan (“Plan”), which
provides severance, wellness, health, dental, and retiree health care benefits for certain eligible
U.S. Bank employees and former employees. The U.S. Bank Comprehensive Welfare Benefit
Plan consists of distinct programs, each of which covers a specific category of benefits for a
particular group of employees. For convenience, U.S. Bank has created a separate summary for
each program. This SPD applies to retirees enrolled in the Early Retiree Medical,
Comprehensive, Medica, UnitedHealthcare or Kaiser Retiree Health Care Program benefit
options.
The materials you receive about your benefit option will include important information regarding
the doctors you may see, the medical services you may receive, any copayments or other out-ofpocket
expenses for which you may be responsible, requirements you must satisfy before
receiving services (e.g., preadmission notification and prior authorization) and the services and
expenses that are excluded under the benefit option. Additionally, your materials may include
specific rules regarding dependent eligibility under the benefit option that may be different from
the other benefit options offered under the Program. It is important for you to read the SPD and
the materials you receive from the UnitedHealthcare or Medica Plan option and Kaiser option (if
applicable) fully and carefully. You should keep these materials available for future reference.
For a list of the summary plan descriptions describing the other benefits under the
U.S. Bank Comprehensive Welfare Benefit Plan, please see the "Benefits Administrative
Information" section of this SPD.
This document is intended only to provide a summary of the benefits that are available. The final
administration of claims is handled by the Claims Administrator. If there is any discrepancy
between this document and the official plan/program documents (for benefits where the
summary plan description is not part of the plan document), the official plan/program documents
govern.
If You Have Questions or Need Information
If you have questions about the U.S. Bank Retiree Health Care Program, call the
U.S. Bank Employee Service Center, which serves employees and retirees, at 1-800-806-7009.
Follow the prompts for retirees or former employees to be directed to the appropriate area.
Representatives are available Monday through Friday (excluding holidays) from 8 a.m. to 8 p.m.
CT. Questions about health care options and what is covered, pre-existing conditions limitations
and/or claims information should be directed to the appropriate third-party administrator or the
insurance company, listed in the “Important Resources” section of this SPD.
You may also access information about the Program at www.yourbenefitsresources.com/usbank.
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Retiree Health Care SPD Effective January 1, 2012
ELIGIBILITY AND ENROLLMENT
The eligibility and enrollment rules for the U.S. Bank Retiree Health Care Program (the
Program) differ based upon your date of retirement and your employee status at the time of
retirement. This section describes the eligibility and enrollment requirements for retirements on
and after January 1, 2012.
See the Appendix to this SPD for the eligibility and enrollment rules for employees who retired
prior to January 1, 2012.
Eligibility and Enrollment Rules
Retiree Eligibility
You are eligible to participate in the Program if:
• you are age 55 or older at the time of your termination, or if you are involuntarily terminated,
the date that your subsidized health care benefits end;
• you have five or more Years of Service as determined under the terms of the U.S. Bank
Pension Plan; except if you are involuntarily terminated, any period of time that you are
enrolled in subsidized health care benefits will count for purposes of calculating a Year of
Service (refer to the “Glossary of Terms” section of this SPD for the definition of Years of
Service);
• you retire from U.S. Bank; and
• you are eligible for and enrolled in a U.S. Bank active employee health care option as of your
termination.
You are not a participant in the Program until you have satisfied all the eligibility requirements
listed above. While certain employees may accumulate retiree health credits while still
employed, the accumulation of these credits does not make employees participants in the
Program.
Note: If you are not eligible for and covered under a U.S. Bank active employee health care
option immediately before your termination, you will not be eligible to participate in the
Program, even if you have accumulated retiree health care credits while employed.
Dependent Eligibility
“Eligible dependents” for the purposes of U.S. Bank benefits are listed below. You will need to
provide your dependent’s Social Security number (SSN) when adding or enrolling a dependent.
Refer to “Dependent Data Requirement” in this SPD for further information about this
requirement. U.S. Bank and its designated administrators may request proof of dependent
eligibility at any time. Failure to provide such proof may result in termination of coverage.
Your dependent(s) will be eligible to participate in the Program, if:
• your dependent was covered by your U.S. Bank active employee health care option at the
time of your termination;
• you are eligible to participate in the Program and you enroll yourself and your eligible
dependent at the time of your termination; and
• your dependent continues to satisfy one of the following requirements:
• Your spouse/domestic partner* (unless legally separated from you). Under the federal
Defense of Marriage Act (DOMA), a spouse is a husband or wife of opposite sex. A
7

Retiree Health Care SPD Effective January 1, 2012
common-law spouse may be covered only if you reside in a state that recognizes
common-law marriage and you meet the common-law requirements at the time you enroll
the dependent in coverage. To enroll a domestic partner in coverage, you must meet the
eligibility criteria defined under “Domestic Partner Eligibility” section in this SPD.
• You or your domestic partner’s children/grandchildren under age 26** who are:
− your/your domestic partner’s biological children;
− your stepchildren;
− your/your domestic partner’s foster children;
− children/grandchildren for whom you or your spouse/domestic partner have legal
guardianship***;
− children/grandchildren legally adopted by you or your spouse/domestic partner or
placed with you or your spouse/domestic partner for adoption***; and
− grandchildren who are eligible to be claimed as an exemption on you or your
spouse/domestic partner’s federal income tax return.
• Disabled children age 26 and older who otherwise meet the dependent children definition
may be covered as long as ALL of the following requirements are met:
– the child is severely disabled by prolonged physical or mental incapacity;
– the child became disabled prior to reaching age 26;
– the child was covered by the plan prior to reaching age 26, or, if older than age 26,
loses coverage under a parent’s/guardian’s plan. In the event of loss of coverage, proof of
prior coverage must be provided;
– the child is unmarried and you/your domestic partner provide more than 50% of his or
her support because he or she is unable to earn a living; and
– disabled dependent status is approved by a medical Claims Administrator for |
U.S. Bank.
*Even though some localities may recognize same-sex marriages, the U.S. Bank Benefits Program is governed by
federal regulations which require that coverage for partners must be paid for on an after-tax basis, and the cost of
coverage be considered imputed income. Therefore, even in the event of marriage or civil union, if you are enrolling
your same-sex spouse you must designate him/her as a domestic partner.
** For health care coverage, a newborn is not considered a dependent until birth.
*** Documentation of legal guardianship or adoption is required. Please call the U.S. Bank Employee Service
Center for instructions. The dependent cannot be added to your coverage until a copy of the applicable documents
are received and verified by the U.S. Bank Employee Service Center.
To have the disabled child considered for coverage, you and his or her doctor must complete an
application form for the child. The form is available from the applicable medical Claims
Administrator. To be considered, the form must be received by the medical Claims
Administrator no later than 30 days after the date the child turns age 26. See the “Important
Resources” section of this SPD for telephone numbers for the medical Claims Administrators. If
the child is approved and the child is not considered permanently disabled, periodically you will
be asked to submit proof to the medical Claims Administrator that the child continues to meet
eligibility requirements. Failure to provide requested information may result in loss of coverage
for the dependent.
If your disabled dependent loses coverage under another health care plan, please contact the
U.S. Bank Employee Service Center for information regarding the procedure for applying for
coverage under the U.S. Bank Retiree Health Care Program.
Children who become disabled after age 26 are not eligible for coverage.
8

Retiree Health Care SPD Effective January 1, 2012
Ineligible Dependents. Ineligible dependents include but are not limited to the following:
• Dependents in the Military. Coverage is not available for any dependent on active duty in
the uniformed services or armed forces of any country.
• Dependent Parents. Coverage is not available for a retiree's or retiree's spouse's/domestic
partner’s parents.
• Former Spouses/Domestic Partners. A spouse from whom you are divorced (even if the
divorce decree stipulates you will continue health care, pharmacy care, dental care or vision
care coverage for your ex-spouse) or legally separated, or a domestic partner or domestic
partner’s dependents if your domestic partnership has ended.
• Spouse/Domestic Partner of Adult Children/Grandchildren. Coverage is not available for
an adult child’s or grandchild’s spouse/domestic partner.
Enrolling ineligible dependents is a violation of company policy and will be treated accordingly.
If U.S. Bank determines that an ineligible dependent has been enrolled, coverage will be
cancelled retroactively. U.S. Bank reserves the right to recover any and all benefit payments
made for services received by ineligible dependents.
For more information about eligibility, enrollment and coverage for domestic partners and
dependents of domestic partners, see the “Domestic Partner Eligibility” section of this SPD.
Enrollment Rules
You may initiate your enrollment into the Program up to 90 days prior to your termination date
by contacting the U.S. Bank Employee Service Center at 1-800-806-7009 or online at
www.yourbenefitsresources.com/usbank. If you are eligible to participate in the Program when
you terminate from U.S. Bank and have not enrolled prior to your termination date, you will
receive enrollment materials that specify an enrollment deadline. You must enroll yourself and
any eligible dependents by the deadline indicated on your election materials; otherwise you and
your dependents will not be covered by the Program.
Coverage Levels. For any of the health care options available to you, you can select from two
coverage levels:
• Individual (yourself - the retiree - only); or
• Family (you, and/or any eligible dependents as previously defined in this section).
Effective Date. If you elect coverage by your enrollment deadline, and are enrolling yourself
and/or your dependents in the Early Retiree Medical or Comprehensive option, coverage is
effective the first day of the month after the date your active employee health care ended or if
you are involuntarily terminated, coverage is effective the first day of the month after the date
your subsidized health care ends. For dependents covered with you as of the date of your
termination or the date your subsidized health care coverage ends, coverage will be effective the
same date as your coverage is effective, if you enroll them at the same time that you enroll. You
will be responsible for the retroactive premiums due for retiree coverage back to the effective
date of your retiree health care coverage.
If you elect coverage by your enrollment deadline, and are enrolling yourself and/or your
dependents in the UnitedHealthcare (UHC) or Medica Plan options, coverage is generally
effective the first day of the month after your application(s) is received and processed. If you will
experience a lapse in coverage between your termination of employment and your effective date
of coverage, you must call the U.S. Bank Employee Service Center at 1-800-806-7009. You will
9

Retiree Health Care SPD Effective January 1, 2012
be responsible for the premiums due for retiree coverage back to the effective date of your retiree
health care coverage.
Deciding Between Retiree Health Care Coverage and COBRA Health Care Coverage.
Separate from the Program enrollment information, you and any other covered dependents will
also receive information on continuing the health care coverage you were enrolled in as an active
employee under the provisions of COBRA. Each of your covered dependents will have an
independent right to decide whether to elect COBRA.
You and your covered dependents will need to decide whether to elect:
• Retiree Health Care Program coverage; or
• COBRA health care coverage.
By electing Retiree Health Care Program coverage, you will waive your COBRA health care
rights. You may, however, revoke such waiver at any time during the 60-day COBRA election
period.
If you elect COBRA health care rather than retiree health care coverage under the
Program, you will not have an option to enroll in the Program when you either stop or
exhaust your COBRA health care coverage.
It is important to carefully compare the benefits of COBRA health care versus retiree health care
coverage in making this decision. If you have questions about the two types of coverage, contact
the U.S. Bank Employee Service Center at 1-800-806-7009.
One-Time Option to Enroll in Retiree Program. There is a single point of entry into the
Program – at the time of your termination. This means that if you do not enroll yourself
and any eligible dependents in the Program by the enrollment deadline stated on your
enrollment worksheet, you will not be able to enroll yourself and/or your dependents in
retiree health care coverage at any time in the future.
If, for example, at the time you terminate, you elect COBRA health care or coverage under a
spouse’s/domestic partner’s plan or a new employer’s plan, instead of coverage under the
Program, you will not be able to enroll in the Program at the time your COBRA health care
continuation period or other coverage ends. Similarly, you must enroll any eligible dependents in
the Program at the time of your termination to retain their coverage. Therefore, if you and/or a
dependent want coverage under the Program at any point after your termination, you must enroll
them when you terminate. You may, however, have the right to add new dependents gained after
your termination. Refer to the “New Dependents Gained After Your Termination” section for
more information.
New Dependents Gained After Your Termination. If you gain a dependent after you terminate
due to marriage, commencement of a domestic partnership, birth, adoption or commencement of
a legal guardianship, your new dependent may be eligible for coverage under the Program if the
following requirements are met:
• You must enroll your new dependent within 60 days of the date they first become your
dependent after your termination; and
• Your new dependent continues to satisfy the requirements of an “eligible dependent”, as
defined in the “Dependent Eligibility” section.
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Retiree Health Care SPD Effective January 1, 2012
If, however, one of your current dependents later gains eligibility due to a change in the
eligibility requirements, you will not be able to enroll that dependent in the Program.
To enroll a new dependent, call the U.S. Bank Employee Service Center at 1-800-806-7009 and
speak to a representative. If your new dependent is a domestic partner or dependent of a
domestic partner, see the “Domestic Partner Eligibility” section in this SPD.
If you are enrolling your dependent(s) into the Early Retiree Medical or Comprehensive option,
your benefit changes will be effective on the first day of the month following the date you
experience a qualifying new dependent enrollment event and contact the U.S. Bank Employee
Service Center to make your election unless:
• You are adding a newborn or newly adopted child (or a child newly placed with you for
adoption). If you are adding a newborn or newly adopted/placed for adoption child,
health care coverage for that dependent will be retroactive to the date of the event. If
coverage is retroactive, premiums will also be retroactive; or
• If your new dependent enrollment event occurs on the first of the month and you contact
the U.S. Bank Employee Service Center on that day your coverage will become effective
on that day.
If you are enrolling your dependent(s) in the UnitedHealthcare or Medica Plan option, coverage
is generally effective the first day of the month after your application is received and processed,
or the first of the month following the date you experience a qualifying new dependent
enrollment event and contact the U.S. Bank Employee Service Center to make your election,
whichever is later.
Coverage Cancellation. You can cancel coverage for yourself and/or your dependents at any
time by calling the U.S. Bank Employee Service Center at 1-800-806-7009. If after electing
coverage when you terminate, you cancel or lose retiree health care coverage under the Program
for any reason (including non-payment of premiums), you will not be able to re-enroll in the
Program. If you cancel or lose retiree health care coverage, any covered dependents will also
lose coverage, subject under certain circumstances and rights to COBRA coverage.
Similarly, if you cancel coverage for an eligible dependent for any reason, that dependent will
not be able to re-enroll in the Program.
If you and/or your dependents are enrolled in one of the Early Retiree Medical or
Comprehensive option, the coverage cancellation effective date is the first of the month
following the date that you contact the U.S. Bank Employee Service Center to cancel coverage
unless you contact the U.S. Bank Employee Service Center on the first of the month, then your
coverage will be canceled on that day.
If you and your dependents are enrolled in the UnitedHealthcare or Medica Plan option, the
coverage cancellation effective date is the first of the month following the date that the U.S.
Bank Employee Service Center receives a written request to disenroll you and/or your
dependents from the UHC or Medica Plan option. This request must be signed and dated by each
member that wants to disenroll from the UnitedHealthcare or Medica Plan option.
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Retiree Health Care SPD Effective January 1, 2012
Additional Eligibility and Enrollment Information
Qualified Medical Child Support Orders
A Qualified Medical Child Support Order (QMCSO) is any judgment, decree or order (including
approval of a settlement agreement) for one parent to provide a child or children with health care
coverage. If U.S. Bank receives a QMCSO for your child or children, you will be contacted
concerning the procedures regarding the order. You may also request a copy of the QMCSO
procedures from the U.S. Bank Employee Service Center at any time and without charge.
Generally, if U.S. Bank receives an order that is determined to be a QMCSO, coverage for the
child who is the subject of the QMCSO will become effective on the date specified in the
QMCSO, or at a later date as specified in U.S. Bank’s QMCSO procedures. In addition, U.S.
Bank will increase your deduction or bill you for appropriate charges beginning on the date the
QMCSO becomes effective. If the request for coverage is not made within 31 days of the date of
the QMCSO, coverage for the child will be subject to all of the terms of the Retiree Health Care
Program, as applicable.
Domestic Partner Eligibility
A domestic partnership consists of an ongoing and committed spouse-like relationship between
adults of the same or opposite gender. If you are in a qualified domestic partnership, your
domestic partner is eligible for health care benefits. (Note: Kaiser Colorado imposes certain
limitations on domestic partner coverage. Contact Kaiser Colorado for specific information on
their coverage.*) Even though some localities may recognize same-sex marriages, the U.S. Bank
Retiree Health Care Program is governed by federal regulations, which require that the cost for
coverage for partners must be considered imputed income. Therefore, even in the event of
marriage or civil union, if you are enrolling your same-sex spouse, you must designate him/her
as a domestic partner.
* Due to Colorado state law, opposite-sex domestic partners and domestic partner children are not eligible for health
care coverage under the Kaiser Colorado option unless the domestic partnership satisfies the state law requirements
for establishing a common-law marriage, which include filing the appropriate documentation with the proper state
agency. Opposite sex domestic partners enrolling in this option will not be eligible to enroll under the domestic
partner process. Rather, the common-law marriage process must be used. Common-law certification forms are
available by calling the U.S. Bank Employee Service Center.
A domestic partnership is qualified if all of the criteria listed below are met:
• The partners have an ongoing and committed spouse-like relationship;
• The partners intend to continue their relationship indefinitely;
• The partners are:
– both 18 years of age or older and competent to enter into a contract;
– not legally married to each other, unless you are same-sex partners who have been
married in a locality that recognizes same-sex marriages as a legal union;
– not legally married to, nor the domestic partner of, anyone else; and
– not related by blood closer than permitted by marriage law in their state of residence.
• The partners share a principal residence and intend to do so indefinitely;
• The partners are responsible for the direction and financial management of their
household and are jointly responsible for each other's financial obligations.
Note: Other rules may apply to Kaiser.
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Retiree Health Care SPD Effective January 1, 2012
Domestic Partner’s Dependent(s) Eligibility. Your domestic partner’s dependents (as
described in the “Dependent Eligibility” section of this SPD) are eligible to be enrolled whether
you enroll your domestic partner in coverage or not.
Enrolling Domestic Partners/Domestic Partner Dependent(s).* To enroll a new domestic
partner or new dependent of a domestic partner, call the U.S. Bank Employee Service Center at
1-800-806-7009. You will need to speak with a representative and indicate that you wish to
enroll your domestic partner/domestic partner’s dependent(s). Note: You must enroll your
domestic partner/domestic partner dependent(s) within 60 days of the date they first become your
dependent after your termination.
*Kaiser may impose limitations on domestic partner coverage. Contact Kaiser for details.
Terminating Domestic Partner/Domestic Partner Dependent Benefits. You must call the
U.S. Bank Employee Service Center no later than 60 days after the date you terminate your
qualified domestic partnership or the date your relationship no longer satisfies the qualification
requirements. Coverage for your domestic partner/domestic partner dependent(s) will terminate
effective the last day of the month in which the relationship ended or no longer satisfied the
qualification requirements. You will receive a revised Confirmation of Coverage statement that
will confirm the changes made and the effect on your monthly premium.
In the event your domestic partnership ends or ceases to be qualified, your domestic partner
and/or your domestic partner’s dependent(s) may be able to elect to continue health care
coverage. If continuation coverage is available, a letter will be sent to your domestic partner
and/or your domestic partner’s dependent(s) informing him or her of the ability to continue
coverage and where to call to obtain this coverage. This continuation coverage is not available to
your domestic partner and/or your domestic partner’s dependent(s) if you fail to call the
U.S. Bank Employee Service Center within 60 days of the date the partnership ended or ceased
to be qualified. (See the “Benefits Administrative Information” section for additional information
on the rights of domestic partners/domestic partner’s dependent(s) to continue coverage.)
If You Marry Your Domestic Partner. If you marry your opposite-sex domestic partner, you
must contact the U.S. Bank Employee Service Center no later than 60 days after the date of your
marriage.
U.S. Bank Retirees Related to Each Other
If you and your spouse/domestic partner are both eligible retirees of U.S. Bank, you may choose
from the following options when enrolling in retiree health care coverage:
• You may each carry Individual coverage (each covers only himself or herself) if you do not
have eligible children, or if they are covered elsewhere.
• Either you or your spouse/domestic partner (but not both of you) may carry Family coverage
(if you have eligible dependent children). The other could then elect Individual coverage if
not covered under the Family level, or No Coverage, if covered under the Family level.
• Either you or your spouse/domestic partner (but not both of you) may carry Family coverage
(if you do not have eligible children, or if your children are covered elsewhere). The other
would then select No Coverage.
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Retiree Health Care SPD Effective January 1, 2012
If you are an eligible retiree of U.S. Bank and your spouse/domestic partner is employed by
U.S. Bank, you may choose from the following options:
• You, as the retiree, may enroll in the U.S. Bank Retiree Health Care Program upon
termination with Individual coverage. Your spouse/domestic partner could then stay in the
U.S. Bank Health Care Program for active employees.
• You may carry Family coverage and cover your spouse/domestic partner as a dependent (and
any other dependents) under the Retiree Health Care Program.
If you are an eligible retiree of U.S. Bank, and your spouse domestic partner is already a
participant in the U.S. Bank Retiree Health Care Program, you may choose from the following
options:
• You may each carry Individual coverage (each covers only himself or herself) if you do not
have eligible children, or if they are covered elsewhere.
• Either you or your spouse/domestic partner (but not both of you) may carry Family coverage
(if you have eligible dependent children). The other could then elect No Coverage.
If your dependent child is employed by U.S. Bank, he or she must enroll in his or her own health
care option from among those available to active employees. Your dependent child may not be
included under your coverage.
Special Rules For Retirees Who Elect Coverage Under The Program And Then Return To
Work With U.S. Bank After Retirement
If you terminate from U.S. Bank, elect retiree health care coverage under the Program, and then
return to work at U.S. Bank, special rules apply. These rules are complex because your options
will depend on when you terminated, the nature of your return to work, and how long you
subsequently work before retiring again. These rules are also subject to U.S. Bank’s generally
reserved right to amend or terminate coverage under the Program (see the “Amendment or
Termination of the Program” section in this SPD). If you return to work with U.S. Bank after
enrolling in the Program, contact the U.S. Bank Employee Service Center for more information
about your options. Some general rules are stated below.
If you are not eligible for health care as an active employee upon your return to work (for
example if you are classified as temporary), you can continue with your retiree health care
coverage under the Program. Your return to work will have no impact on your continued
eligibility under the Program. If you drop coverage under the Program during your
reemployment, however, you will not be able to re-enroll in the Program upon your subsequent
termination from U.S. Bank.
If you return to work for U.S. Bank and become eligible for active employee health
coverage again, you can choose between continued participation in retiree coverage and reenrollment
in an active employee health care option. You will be able to enroll in active
employee coverage, if eligible, upon rehire, at any subsequent annual enrollment periods that you
are still employed, or if you have a family status change. If you elect coverage in an active
employee health care option, you will not be able to switch from active coverage to retiree
coverage during your period of re-employment.
If you elect coverage under an active employee health care option, when you terminate from U.S.
Bank a second time, you will be able to resume coverage under the Program, as long as you are
covered under an active employee health care option at the time of your second retirement. If at
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Retiree Health Care SPD Effective January 1, 2012
the time of your second retirement you have no coverage in place from U.S. Bank under either
the active employee health care option or retiree coverage under the Program, you will not be
eligible for any further coverage under the Program after your second retirement.
Regardless of which option you choose (continued participation in the Program or coverage
under the active employee health care program), remaining accumulated retiree health care
credits (if any) will continue to earn interest during your period of re-employment. If you remain
enrolled in the Program and you are eligible for additional credits while reemployed, your credits
will be added to your balance annually.
If you have a Year of Service after re-employment, the Year of Service will count toward
additional credits if you did not have 15 years of retiree health care credits when you initially
terminated and if you satisfy requirements for receiving credits. The Break in Service rules from
the U.S. Bank Pension Plan will determine whether Years of Service that pre-date your original
termination count for purposes of eligibility for or accumulating credits. When you retire again
from U.S. Bank, you will receive any additional credits you accumulated while reemployed, plus
any credits accumulated before your original retirement up to the 15 year maximum, less any
payments toward coverage under the Program during your initial period of coverage. Refer to the
“Retiree Health Care Credits” section in this SPD for more information.
If You Retired Under Another Retiree Cost Sharing Arrangement Than Retiree Health
Care Credits. If you retired, elected retiree health coverage under another cost sharing
arrangement than retiree health care credits, and then return to active employee health coverage,
generally when you leave U.S. Bank again you will have a choice between the retiree cost
sharing arrangement you initially left under (if any) and any retiree health care credits you
accumulate after your reemployment. If this situation applies to you, U.S. Bank will provide you
with more information.
If You Retired Initially from U.S. Bank During 2002 and are a Former West Employee
Who Elected a Fixed Subsidy. If you are a former West employee who elected the Fixed
Subsidy at retirement in 2002, upon your second retirement you will be able to choose between
your Fixed Subsidy (on the same terms as at the time of your original retirement) or retiree
health care credits, if any, that you accumulated during your subsequent period of employment.
At the time of your initial retirement, you will, however, have forfeited any retiree health care
credits available to you at that time, and these will not be restored to you if you elect retiree
health care credits at your second retirement.
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Retiree Health Care SPD Effective January 1, 2012
RETIREE HEALTH CARE OPTIONS
The health care option available to you depends on your age (as the U.S. Bank retiree), Medicare
eligibility and the area in which you live.
• If you are under age 65 (and not Medicare eligible), you can enroll yourself and your
eligible dependents (regardless of their ages) in the pre-65 health care option available in
your location.
• If you and your eligible dependents are age 65 or older or pre-65 and Medicare eligible,
you and your eligible dependents must enroll in the UnitedHealthcare or Medica Plan
option available in your area.
• If you are age 65 or older but your covered dependents are under age 65 and not
Medicare eligible, you must enroll in the UnitedHealthcare or Medica option available in
your area and your covered dependents can enroll in the pre-65 health care option
available in your area.
Your Health Care Options — Retirees Under Age 65 and non-Medicare
Eligible
The option available to you at your initial enrollment is listed on your enrollment form and
depends on where you live.
Choices for retirees under age 65 are:
Option Claims Administrator(s)
No Coverage
Early Retiree Medical (in locations with access to the BCBS BCBS of MN
BlueCard PPO network)
Comprehensive (in locations without access to the BCBS BCBS of MN
BlueCard PPO network)
Blue Cross and Blue Shield of Minnesota and other Blue Cross Blue Shield plans are independent licensees of the
Blue Cross Blue Shield Association.
Following is a brief summary of the pre-65 non-Medicare eligible health care options.
Early Retiree Medical Option
This option is available to pre-65 non-Medicare eligible retirees and their dependents and is
available in areas that have access to the BCBS BlueCard PPO network. This option is
administered by Blue Cross and Blue Shield of Minnesota. Specific details about the deductible
and out-of-pocket maximum related to each option can be found in the “Health Care Option
Summary” section in this SPD. Under this option:
• You may choose any provider each time you need care – either in or out of the BCBS
BlueCard PPO network. However, your benefit level depends on the provider you select.
If you use an in-network provider, your expenses are generally covered at a higher level.
Refer to the “Which Network Providers to Use” section in this SPD for more information
on the provider networks. Benefits are not available for preventive care if you use an outof-network
provider.
• If either your physician or your clinic leaves the network, you must select another
physician or clinic affiliated with your network in order to receive in-network benefits.
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Retiree Health Care SPD Effective January 1, 2012
• Pharmacy services are included and administered by Medco Health Solutions (Medco).
You will need to use your Medco ID card when using these services. Detailed
information on pharmacy coverage can be found in the “Pharmacy Coverage Summary”
section in this SPD.
Comprehensive Option
This option is generally available to pre-65 non-Medicare eligible retirees and their dependents
that do not have adequate access to the BCBS BlueCard PPO network (although there may be
BCBS participating providers in the area). This option is administered by Blue Cross and Blue
Shield of Minnesota. Under this option:
• You may choose any provider each time you need care – either in or out of the BlueCard
Traditional network. However, your benefit level depends on the provider you select. If you
use a BlueCard Traditional provider, your expenses are generally covered at a higher level.
Refer to the “Which Network Providers to Use” section in this SPD for more information on
the provider network.
• If either your physician or your clinic leaves the BlueCard Traditional network, you must
select another physician or clinic in the BlueCard Traditional network in order to receive
“participating provider” benefits.
• Pharmacy services are included and administered by Medco Health Solutions (Medco). You
need to use your Medco ID card when using these services. Detailed information on
pharmacy coverage can be found in the “Pharmacy Coverage Summary” section in this SPD.
Kaiser Colorado Option
This option is no longer available to retirees effective January 1, 2009. If you were already
enrolled in the Kaiser option prior to January 1, 2009, you may remain in this option.
If you are enrolled in the Kaiser option, generally you will receive benefits only for covered
services you receive from a provider within Kaiser. If you receive non-emergency services from
a provider outside Kaiser, you will likely receive no benefits. The Kaiser option is offered
through insurance contracts with Kaiser Permanente. Kaiser has the sole authority, discretion and
responsibility to interpret and construe the option and, determine all factual and legal questions
under such option, including but not limited to eligibility, the entitlement of benefits and the
amounts of benefits to be paid, and determine all questions arising in the administration of the
option.
Kaiser Colorado provides its own materials. Be sure to refer to those materials, as Kaiser may
have different provisions and requirements than those described in this SPD.
Kaiser Mergers/Terminations/Provider Changes. If you are enrolled in Kaiser and Kaiser
merges with another company and is no longer offered by U.S. Bank, or if Kaiser terminates
operations during the year, you will be enrolled in either the Early Retiree Medical or the
Comprehensive option (depending on whether you have access to the BCBS BlueCard PPO
network or not in your area).
If either your physician or your clinic leaves Kaiser, you must select another physician or clinic
affiliated with Kaiser – you will not be able to change health care options under this
circumstance.
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Retiree Health Care SPD Effective January 1, 2012
Dependents. Kaiser's definition of dependent(s) may be different than the definition used by
other U.S. Bank options described in this document. This plan is subject to state regulations.
Refer to the Kaiser materials, or contact Kaiser's member service department for details. (See the
“Important Resources” section of this SPD for phone numbers and Web site addresses.)
Additional Information About Your Health Care Options
If your covered dependents are age 65 or older or pre-65 and Medicare eligible and are
enrolled in one of the pre-65 health care options, the U.S. Bank Retiree Health Care
Program expects your covered dependents will enroll in Medicare Parts A and B as soon as
they are eligible to do so. Medicare Parts A and B will be considered the primary insurer,
regardless of whether your covered dependents are actually enrolled in Medicare or not
and your U.S. Bank Retiree Health Care Program will provide secondary coverage. This
means you will be responsible for paying the portion Medicare would have paid had your
dependents been enrolled in Medicare when first eligible, in addition to any liability you
may be responsible for under your coverage in the Program. Be sure to read the “How
Coverage Works If You Are Age 65 Or Older Or Pre-65 And Medicare Eligible” section in
this SPD regarding these dependents.
More information about your health care coverage is provided in the “How Coverage Works If
You Are Under Age 65 And Not Medicare Eligible” section in this SPD.
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Retiree Health Care SPD Effective January 1, 2012
Your Health Care Options — Retirees Age 65 or Older or Pre-65 and
Medicare Eligible
For retirees age 65 or older (or pre-65 and Medicare eligible), your health care choices are:
Option Claims Administrator
No Coverage
UnitedHealthcare® Group Medicare Advantage PPO UnitedHealthcare
Medica Group Prime Solution SM Medica
UnitedHealthcare or Medica Plan Option
The UnitedHealthcare or Medica Plan options are available to Medicare eligible retirees and
their dependents (as long as the retiree is also enrolled in this option). The option that you are
offered is based on your permanent address. If you are enrolled in the UnitedHealthcare or
Medica Plan option, you will generally receive benefits only for covered services you receive
from providers that accept the terms of the UnitedHealthcare or Medica Plan option that you are
enrolled in. The UnitedHealthcare or Medica Plan options are offered through insurance
contracts with UnitedHealthcare and Medica. UnitedHealthcare and Medica have the sole
authority, discretion and responsibility to interpret and construe the option and, determine all
factual and legal questions under such option, including but not limited to eligibility, the
entitlement of benefits and the amounts of benefits to be paid, and determine all questions arising
in the administration of the option.
If you elect to enroll in the UnitedHealthcare or Medica Plan option, you must be enrolled in
Medicare Parts A and B. The option you are enrolled in will depend on the area where you live.
These plans deliver all of the benefits of Medicare Parts A and B, plus additional benefits. (See
the separate materials from UnitedHealthcare or Medica.)
You will be enrolled in the Medica Group Prime Solution SM , a Medicare Cost plan, if you live in
any of the following areas:
• Minnesota – all counties
• North Dakota counties of Adams, Barnes, Bowman, Burleigh, Cass, Cavalier, Dickey,
Dunn, Eddy, Emmons, Foster, Grand Forks, Grant, Griggs, Hettinger, Kidder, LaMoure,
Logan, McHenry, McIntosh, McLean, Mercer, Morton, Oliver, Pembina, Pierce,
Ransom, Richland, Sargent, Sheridan, Sioux, Start, Steele, Stutsman, Traill, Walsh, Ward
• South Dakota counties of Aurora, Beadle, Bennett, Bon Homme, Brookings, Brown,
Brule, Buffalo, Butte, Campbell, Charles Mix, Clark, Clay, Codington, Custer, Davison,
Day, Deuel, Dewey, Douglas, Edmunds, Fall River, Grant, Gregory, Haakon, Hamlin,
Hand, Hanson, Harding, Hughes, Hutchinson, Jackson, Jerauld, Jones, Kingsbury, Lake,
Lawrence, Lincoln, Lyman, Marshall, McCook, McPherson, Meade, Mellette, Miner,
Minnehaha, Moody Pennington, Perkins, Roberts, Sanborn, Shannon, Spink, Stanley,
Todd, Tripp, Turner, Union, Yankton, Ziebach
• Wisconsin counties of Ashland, Barron, Bayfield, Burnett, Chippewa, Douglas, Dunn,
Eau Claire, Pierce, Polk, Sawyer, St. Croix or Washburn
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Retiree Health Care SPD Effective January 1, 2012
All other retirees will be enrolled in the UnitedHealthcare® Group Medicare Advantage PPO M
Plan.
UnitedHealthcare and Medica provide their own materials. If you elect to enroll in the Program,
you should carefully review and refer to these materials.
Questions about your health care option, coverage and claims information should be directed to
UnitedHealthcare or Medica. See the “Important Resources” section of this SPD.
Kaiser Colorado Option
Retirees enrolled in the Kaiser option prior to January 1, 2009 will continue to be enrolled in this
option. If you are enrolled in the Kaiser option, you will generally receive benefits only for
covered services you receive from a provider within Kaiser. If you receive non-emergency
services from a provider outside Kaiser, you will likely receive no benefits. The Kaiser option is
offered through insurance contracts with Kaiser Permanente. Kaiser has the sole authority,
discretion and responsibility to interpret and construe the option; determine all factual and legal
questions under such option, including but not limited to eligibility, the entitlement of benefits
and the amounts of benefits to be paid; and determine all questions arising in the administration
of the option.
Kaiser Colorado provides its own materials. Be sure to refer to those materials, as Kaiser may
have different provisions and requirements than those described in this SPD.
If you will be moving out of the Kaiser service area and you are Medicare eligible, you must
enroll in the UnitedHealthcare or Medica Plan option (depending on your new zip code) in order
to continue coverage under the Program. Contact the U.S. Bank Employee Service Center at 1-
800-806-7009 sixty days prior to your move date.
Kaiser Mergers/Terminations/Provider Changes. If you are enrolled in Kaiser and Kaiser
merges with another company and is no longer offered by U.S. Bank, or if Kaiser terminates
operations during the year, and you are Medicare eligible you must enroll in the
UnitedHealthcare or Medica Plan option available in your area in order to continue coverage
under the Program. Information on your options will be provided to you at that time.
If either your physician or your clinic leaves Kaiser, you must select another physician or clinic
affiliated with Kaiser – you will not be able to change health care options under this
circumstance.
Dependents. Kaiser's definition of dependent(s) may be different than the definition used by
other U.S. Bank options described in this document. Refer to the Kaiser materials, or contact
Kaiser's member service department for details. (See the “Important Resources” section of this
SPD for phone numbers and Web site addresses.)
Dependent Data Requirement
Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) is a federal
law that became effective January 1, 2009. This federal law requires U.S. Bank to provide the
Social Security number (SSN) for your covered dependents that are U.S. citizens. Newborn
dependents are also included in this requirement. This information is reported to assist the
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Retiree Health Care SPD Effective January 1, 2012
Centers for Medicare and Medicaid Services (CMS) and health plans to properly coordinate
payment of benefits among plans. Compliance is required in order to provide coverage for your
dependents. When adding or enrolling a dependent, you will want to have that information
available in order to complete the enrollment process.
If you cannot or do not wish to provide your dependent’s SSN, you will need to call the
U.S. Bank Employee Service Center at 800-806-7009 and speak with a representative. You
should call:
• If your dependent doesn’t have a SSN because he/she is not a U.S. citizen. Providing a
dependent’s Tax Identification number (TIN) in place of the SSN is not sufficient.
• If your dependent is a newborn and you have not yet been issued a Social Security
number for the child.
• If you wish to complete the form indicating your dependent is not a Medicare beneficiary
or you refuse to provide the requested information. Please note that this form will need to
be completed annually until the Social Security number is provided or the dependent is
no longer covered.
Pre-Existing Conditions Limitations*
Note: The Pre-existing Conditions Limitations provisions do not apply to East Employees who
retired before January 1, 2002, former Mercantile Employees who retired before January 1,
2003, or dependents under age 19.
The Program has a 12-month pre-existing conditions limitation for retirees and their dependents
(age 19 and older). However, if you enroll when you are first eligible, the pre-existing conditions
limitation will not apply to you or any dependents who had coverage under a U.S. Bank active
employee health care option for at least 12 months immediately preceding your termination date.
That is because your coverage under a U.S. Bank health care option while you were an active
employee is considered creditable coverage.
If you or an eligible dependent (age 19 or older) was not covered by a U.S. Bank active
employee health care option for the 12 months prior to your enrollment in the Program, you will
need to provide the U.S. Bank Employee Service Center with a certificate of creditable coverage
from your prior plan(s). Most group health plans, health insurers and HMOs automatically
furnish these certificates when coverage is lost. In addition, all plans, insurers and HMOs are
required to provide these certificates upon request. The certificate will tell U.S. Bank how long
you had coverage under your prior plan(s) and when it ended. Most prior coverage will count as
creditable health coverage if there has not been a period of 63 or more consecutive days without
coverage. Creditable coverage will reduce the duration of the pre-existing-conditions limitation
period under this Program, as explained below.
*If you are enrolled in the Kaiser Colorado, UnitedHealthcare or Medica plan option, see the separate material
provided by Kaiser, UnitedHealthcare and Medica.
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Retiree Health Care SPD Effective January 1, 2012
How to Show Previous Creditable Coverage
Obtain a certificate of creditable coverage from your previous insurer. Call the U.S. Bank
Employee Service Center at 1-800-806-7009 to find out how and where to submit your
certificate of creditable coverage.
You have the right to request a certificate from a prior plan, insurer, HMO or other entity
through which you had creditable coverage. If, after making reasonable efforts, you have
difficulty getting a certificate from your prior plan, insurer, HMO or other entity through which
you had creditable coverage, please contact the U.S. Bank Employee Service Center at 1-800-
806-7009 for assistance.
Without creditable prior coverage, coverage under any Program option is subject to a 12-month
pre-existing conditions limitation. A pre-existing condition is any chronic and/or ongoing
condition (other than pregnancy) for which you or a covered dependent (age 19 or older) has
received prescription medications or treatment or for which treatment was recommended during
the six months prior to the effective date of your coverage.
Pre-existing conditions include such things as cancer, ear infections, heart and other organ
disorders, diabetes, and other chronic conditions, but exclude conditions such as the flu, where
the condition is treated and cured. Treatment includes visiting a physician for diagnosis, advice
or care, and such actions as taking prescription medication to control an illness. Although some
conditions, such as ear infections, may appear to have been treated and cured, they are
considered chronic because they frequently recur.
No pre-existing-conditions limitation will apply to pregnancy or to newborn/newly adopted
dependents or for dependents under age 19. If you have questions regarding whether a condition
will be considered pre-existing, call your Claims Administrator’s customer service department at
the number listed on the “Important Resources” section of this SPD.
Any costs relating to a pre-existing condition will not be covered under the Program for a
maximum of 12 months from the enrollment date. (Refer to the “Glossary of Terms” section for
a definition of Enrollment Date.) This 12-month period will be reduced by the number of days of
prior creditable health coverage, if any, applicable to you or your dependent with a pre-existing
condition. After the U.S. Bank Employee Service Center receives your certificate of creditable
coverage, you will be notified about the determination of U.S. Bank of any prior creditable
coverage that will reduce a pre-existing-conditions limitation period.
Individuals who have a pre-existing condition and who do not have 12 months of creditable
coverage may want to continue their previous coverage until the end of their pre-existing
condition limitation period.
To allow claims to be processed more efficiently, your Claims Administrator may pay some
claims related to a pre-existing condition. Please be aware that payment of a claim for a preexisting
condition will not eliminate the possibility of such coverage being denied at a future
date. For example, a claim for an office visit related to a pre-existing condition may be paid, but
a subsequent surgery claim for the condition may be denied.
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Retiree Health Care SPD Effective January 1, 2012
Wellness
General Information and Eligibility
The U.S. Bank Wellness Program, is designed to provide eligible employees and retirees with
health education and information materials and services.
Optimal Health® care support program: offers resources and support for retirees living with
certain chronic conditions enrolled in the Comprehensive or Early Retiree Medical health care
options.
U.S. Bank will distribute the health education and information materials from time to time as it,
in its sole discretion, determines. There may be no distributions of materials or provisions of
services in a given year. Information about additional materials or services provided under this
program will be announced as they become available.
Retirees who are under age 63 are eligible to participate, as are their dependents, regardless of
age. Those who enroll may remain in the program until the first day of the month in which the
retiree becomes Medicare eligible.
Persons deemed eligible will receive an invitation to participate in the program via mail and/or
telephone. Enrollment and participation is voluntary, confidential and paid for by U.S. Bank.
Filing Claims
If you do not receive materials or services you believe you are entitled to, contact the U.S. Bank
Employee Service Center at 1-800-806-7009. If this does not resolve the issue, you may file a
claim and seek review of that claim by submitting it in writing to:
U.S. Bank Benefit Claim Subcommittee
EP-MN-R2BN
4000 W. Broadway
Robbinsdale, MN 55422-2299
Fax: 763-971-1285
Within 60 days after your claim is received, you will receive a written notice of the decision. If
your claim is denied, in whole or in part, the Claim Reviewer will further notify you of your right
to additional review of your denied claim.
If your request for review is denied in whole or in part and you still disagree with the decision,
within 60 days of the date you receive written notice, you must deliver to the U.S. Bank Benefit
Claim Subcommittee a written request for a final claims determination at the above address.
Your request for a final claims determination should include any documentation supporting your
claim.
Termination of Participation
Your participation in this program ends the day you cease to be enrolled in an eligible selfinsured
health care option. You may also decline or terminate participation at any time, since
participation is voluntary.
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Retiree Health Care SPD Effective January 1, 2012
DEDUCTIBLES, COINSURANCE AND
MAXIMUMS
Note: If you are enrolled in Kaiser Colorado, UnitedHealthcare or Medica Plan options, this
information does not apply to you. Please see the separate Kaiser, UnitedHealthcare or Medica
Plan options materials.
Deductibles
A deductible is the per plan year amount you must pay toward eligible expenses before you and
the health care option begin to share covered expenses. The deductible is applied to the out-ofpocket
maximum. The medical and pharmacy deductibles under the health care options work
differently as explained below. The deductibles stated are for in-network/participating providers
only. Information for out-of-network/non-participating deductibles can be found in the “Health
Care Option Summary” section in this SPD.
Early Retiree Medical Option
The Early Retiree Medical option has a combined medical/pharmacy deductible and the
deductible is non-embedded, which means:
• If you elect the Individual coverage level, you only need to meet the per person
deductible of $2,000.
• If you elect the Family coverage level, you will need to meet the Family deductible of
$3,000. The Family deductible can be met by one covered member or any combination of
covered members. The per person deductible does not apply.
Example 1. Sally is covered under the Early Retiree Medical option at the Individual level.
She must have eligible expenses of $2,000 before she and the Program begin to share
covered expenses.
Example 2. Joe is covered under the Early Retiree Medical option at the Family level. He
and his spouse must have eligible expenses of $3,000 before he and the Program begin to
share covered expenses.
Example 3. Tim is covered under the Early Retiree Medical option at the Family level, with
his spouse and two children enrolled. He and his family must have eligible expenses of
$3,000 before he and the Program begin to share covered expenses.
For the Early Retiree Medical option the following charges do not apply to your combined
medical/pharmacy deductible:
• Your monthly health care premiums.
• Any costs not covered by your option.
• Any amounts that exceed the Program's allowed amounts when non-participating providers
are used for medical services. In certain locations, this also applies when out-of-network
providers are used. Refer to the “Which Network Providers to Use” section in this SPD for
more information.
• Any penalty for failing to provide required preadmission notification.
24

Retiree Health Care SPD Effective January 1, 2012
• Any amounts that exceed the Program's allowed amounts when a non-participating Retail
Pharmacy is used for pharmacy services. This also applies if you use a participating Retail
Pharmacy, but do not show your Medco ID card or for compound prescriptions not submitted
directly to Medco by the pharmacy.
• Any cost difference between a brand-name drug and a generic equivalent when a brand-name
drug is prescribed and a generic drug is available.
• Specialty drugs not filled by Accredo (a division of the Medco Pharmacy for specialty drugs)
when required.
• Any maintenance medications not filled by the Medco Pharmacy (Medco’s mail order
service) after the first two fills when required.
Comprehensive Option
The Comprehensive option has separate medical and pharmacy deductibles, they are not
combined and this deductible is embedded, which means:
• If you elect the Individual coverage level, you only need to meet the per person
deductible of $600.
• If you elect the Family coverage level (but only have one or two covered dependents),
you will each be responsible for the per person deductible of $600.
• If you elect the Family coverage level (with at least 3 covered dependents), the family
deductible of $1800 can be met by any combination of three or more covered members.
Example 1. Ron is covered under the Comprehensive option at the Individual level. He must
have eligible expenses of $600 before he and the Program begin to share covered expenses.
Example 2. Alice is covered under the Comprehensive option at the Family level, with only
her son enrolled. Both she and her son must each have eligible expenses of $600, before she
and the Program begin to share covered expenses.
Example 3. Barb is covered under the Comprehensive option at the Family level, with her
spouse and three children enrolled. If Barb and her spouse and one of her children has $1,800
in eligible expenses, the Program will share covered expenses for any of the covered family
members.
For the Comprehensive option the following charges do not apply to your medical deductible:
• Your monthly premium contributions for Program coverage.
• Any costs not covered by your option.
• Any amounts that exceed the Program's allowed amounts when non-participating
providers are used for medical services. In certain locations, this also applies when outof-network
providers are used. Refer to the “Which Network Providers to Use” section in
this SPD for more information.
• Any penalty for failing to provide required preadmission notification.
• Amounts paid toward the pharmacy deductible.
• Coinsurance and copayments for retail, Medco Pharmacy (Medco’s mail order service)
and Accredo (a division of the Medco Pharmacy for specialty drugs).
• Copayments for emergency room visits.
• Charges that are not eligible to be applied to the pharmacy deductible are also not eligible
to be applied to the medical deductible. See the “Pharmacy Deductibles, Coinsurance and
Maximums” section in this SPD for the list.
25

Retiree Health Care SPD Effective January 1, 2012
Copayments and Coinsurance
Copayments are payments you make on a per service basis for eligible expenses after the
deductible has been satisfied. Copayments are applied to the out-of-pocket maximum. For
example, after the deductible is satisfied, you will pay a $150 copayment along with your
coinsurance for emergency room services if you are enrolled in the Early Retiree Medical option.
Copayments for the Early Retiree Medical and Comprehensive options can be found in the
“What the Options Cover” charts in this SPD. Copayments related to pharmacy coverage for
these options can be found in the “Pharmacy Coverage Summary” section in this SPD.
Coinsurance is a percentage of the cost of the service that you pay for eligible expenses once the
deductible has been satisfied. The cost is the lesser of the allowed amount and the provider's
actual billed charge. How much coinsurance you pay (after your applicable deductible and/or
copayment is met) depends on the service received and if you use an in-network/participating
provider or not. The coinsurance you pay is applied to the out-of-pocket maximum. If you
receive services from a non-participating provider, you will also be responsible for paying any
amount in excess of the allowed amount in addition to coinsurance. In certain locations, this also
applies when out-of-network providers are used. Refer to the “Which Network Providers to Use”
section in this SPD for more information. The excess amount you pay will not be applied to the
out-of-pocket maximum. A change to the cost during a plan year will not result in a recalculation
of any coinsurance paid. Coinsurance for the Early Retiree Medical and Comprehensive options
can be found in the “Health Care Option Summary” section in this SPD. Coinsurance related to
pharmacy coverage for these plans can be found in the “Pharmacy Coverage Summary” section
in this SPD.
Out-of-Pocket Maximum
The out-of-pocket maximum is the per plan year limit you must pay toward eligible expenses
before any additional eligible services you incur are paid by the Program at 100% of the allowed
amount for the remainder of the year (as long as any applicable annual or lifetime maximums
have not been exceeded). The limit you pay includes the total of the applicable deductible,
copayments and coinsurance. The out-of-pocket maximum under the health care options is
explained below. The out-of-pocket maximums stated are for in-network/participating providers
only. Information for out-of-network/non-participating out-of-pocket maximums can be found in
the “Health Care Option Summary” section in this SPD.
Early Retiree Medical Option
The Early Retiree Medical option has a combined medical/pharmacy out-of-pocket maximum
and the out-of-pocket-maximum is non-embedded, which means:
• If you elect the Individual coverage level, you only need to meet the per person out-ofpocket
maximum of $5,000.
• If you elect the Family coverage level, you will need to meet the Family out-of-pocket
maximum of $7,500. The Family out-of-pocket maximum can be met by one covered
member or any combination of covered members. The per person out-of-pocket
maximum does not apply.
Comprehensive Option
The Comprehensive option has separate medical and pharmacy out-of-pocket maximums; they
are not combined and the out-of-pocket maximum is embedded, which means:
26

Retiree Health Care SPD Effective January 1, 2012
• If you elect the Individual coverage level, you only need to meet the per person out-ofpocket
maximum of $1,750.
• If you elect the Family coverage level (but only have one or two covered dependents),
each of you will be responsible for the per person out-of-pocket maximum of $1,750. The
Family out-of-pocket maximum does not apply since it’s the same as each per person
amount that applies to you and your covered dependent.
• If you elect the Family coverage level (with at least three dependents covered), the per
person out-of-pocket maximum of $1,750 will apply if one covered member meets this
amount on their own and at least two other covered member will be responsible for the
remaining per person out of pocket maximum of $1,750. Otherwise the Family out-ofpocket
maximum of $5,250 can be met by any combination of at least three or more
covered members if none of the covered members can meet the per person out-of-pocket
maximum of $1,750 on their own.
The charges that do not apply to your deductible (listed previously) also do not apply to your
out-of-pocket maximum, except for copayments.
27

Retiree Health Care SPD Effective January 1, 2012
HEALTH CARE OPTIONS SUMMARY
Early Retiree Medical Option
In-Network*
Combined Pharmacy/Medical
Deductible (non-embedded)** per
plan year
(Level 1) †
You pay $2,000/person (only applies if the
Individual coverage level elected)
Out-of-Network*
You pay $3,100/person (only applies if the
Individual coverage level elected)
You pay $3,000/Family
You pay $4,100/Family
Medical Coinsurance** You pay 25% You pay 45%
Combined Pharmacy/Medical You pay $5,000/person (only applies if the You pay $11,200/person (only applies if the
Out-of-Pocket Maximum (nonembedded)**
per plan year
Individual coverage level elected) Individual coverage level elected)
You pay $7,500/Family
You pay $16,800/Family
Program Lifetime Maximum*** No maximum paid by the Program No maximum paid by the Program
See the section “Glossary of Terms” in this SPD for all definitions and the “Deductibles,
Coinsurance and Maximums” section in this SPD for more information.
* In-network and out-of-network deductibles, out-of-pocket maximums, annual maximums and lifetime maximums
accumulate jointly; e.g., if you use an out-of-network provider, the amount applied to your out-of-network
deductible also counts toward your in-network deductible, and vice versa.
** Deductible and Maximum out of pocket is per plan year.
*** Refer to the “What the Options Cover” section in this SPD for specific annual and/or lifetime maximums for
certain medical services. See the “Pharmacy” section in this SPD for specific annual and/or lifetime maximums for
certain prescription drugs.
† See the “Which Network Providers to Use” section in this SPD for more information.
Refer to the “Pharmacy” section in this SPD for information related to pharmacy coverage
included under this Program.
28

Retiree Health Care SPD Effective January 1, 2012
Comprehensive Option
Deductible (embedded)** per plan
year
Medical Coinsurance**
Out-of-Pocket Maximum
(embedded)** per plan year
Participating
Provider*
Medical
You pay $600/person
You pay $1,800/family
Pharmacy
See the “Pharmacy” section in this
SPD
Medical
You pay 20%
Pharmacy
See the “Pharmacy” section in this
SPD
Medical
You pay $1,750/person
You pay $5,250/family
Pharmacy
See the “Pharmacy” section in this
SPD
Non-Participating
Provider*
Medical
You pay $600/person
You pay $1,800/family
Pharmacy
See the “Pharmacy” section in this
SPD
Medical
You pay 40%
Pharmacy
See the “Pharmacy” section in this
SPD
Medical
You pay $2,750/person
You pay $8,250/family
Pharmacy
See the “Pharmacy” section in this
SPD
Program Lifetime Maximum*** No maximum paid by the Program No maximum paid by the Program
See the section “Glossary of Terms” in this SPD for all definitions and the “Deductibles,
Coinsurance and Maximums” section in this SPD for more information.
*Participating provider and non-participating provider deductibles, out-of-pocket maximums, annual maximums and
lifetime maximums accumulate jointly; e.g., if you use a non-participating provider, the amount applied to your nonparticipating
provider deductible also counts toward your participating provider deductible, and vice versa. See the
“Which Network Providers to Use” section in this SPD for more information about the network.
** Deductible and Maximum out of pocket is per plan year.
*** Refer to the “What the Options Cover” section in this SPD for specific annual and/or lifetime maximums for
certain medical services. See the “Pharmacy” section in this SPD for specific annual and/or lifetime maximums for
certain prescription drugs.
Refer to the “Pharmacy” section in this SPD for information related to pharmacy coverage
included under this Program.
29

Retiree Health Care SPD Effective January 1, 2012
WHAT THE OPTIONS COVER
Early Retiree Medical Option
The benefit charts on the next several pages describe the services for the Early Retiree Medical
option. You are responsible for paying the difference between the provider’s billed charge and
the BCBS allowed amount when using non-participating providers. In certain locations, this also
applies when out-of-network providers are used. See the section “Which Network Providers to
Use” in this SPD for more information. If a service is not listed, it is likely not a covered service.
Please call your medical Claims Administrator if you have questions about coverage for a
specific procedure. Telephone numbers are listed in the “Important Resources” section in this
SPD.
Service¹
Participating
Provider/In-
Network
Coinsurance²
Non-
Participating
Provider/Outof-Network
Coinsurance² Special Notes
Acupuncture You pay 25% You pay 45% Coverage is limited to pain management only and services must be
provided as part of a comprehensive pain management program after
all other treatment options have failed. Coverage also provided for
prevention and treatment of nausea associated with surgery,
chemotherapy or pregnancy.
Allergy Testing
and Treatment
You pay 25% You pay 45%
No coverage for therapeutic acupuncture, weight loss management,
smoking cessation or other non-listed purposes.
Coverage provided for testing, serum, and allergy shots.
Ambulance You pay 25% You pay 25% Coverage is limited to air or ground transportation from the place of
departure to the nearest facility equipped to treat the illness, and to
prearranged medically necessary air or ground ambulance
transportation requested by an attending physician or nurse. If the
Claims Administrator determines air ambulance was not medically
necessary but ground ambulance would have been medically
necessary, the plan pays up to the BCBS allowed amount for ground
ambulance.
Benefit
You pay 25% You pay 45% If the benefit substitution of treatment is a prescription drug, see the
Substitution
“Pharmacy” section in this SPD.
Chemical
Dependency/
Substance Abuse
Chiropractic
Services
Cleft Lip and
Palate
Benefit substitution is a course of treatment approved and authorized
by a BCBS case manager as an alternative to the services and supplies
that would otherwise have been covered by the Program. The benefit
substitution must be at a cost equal to or lower than that of the care
being provided and maintain the same quality of care. Failure to
follow an approved treatment plan may result in nonpayment of
services. Call the customer service number on your ID card for
further information.
You pay 25% You pay 45% See the “Mental Health and Substance Abuse Coverage” section in
this SPD for more details.
You pay 25% You pay 45% Limited to 25 visits paid by the plan per plan year.
You pay 25% You pay 45% Coverage only provided for a dependent child under age 19. Dental
implants and orthodontia services provided as part of the treatment
would be eligible.
¹ Refer to the “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits” section in this SPD to see if
any action is recommended or required on your part before receiving the service.
² The percentage in this column is based on the BCBS allowed amount. All coinsurance amounts (unless otherwise noted) are
paid after the deductible has been satisfied. Refer to the “Health Care Option Summary” section in this SPD for the deductible
information related to your health care option.
30

Retiree Health Care SPD Effective January 1, 2012
Early Retiree Medical Option, continued
Service¹
Cosmetic,
Reconstructive or
Plastic Surgery
Dental-Related
Services
Dental services covered
under the U.S. Bank
Retiree Health Care
Program are limited to:
1. Treatment of
fractured jaw
2. Accident-related
dental services from a
physician or dentist for
the treatment of an
injury to sound and
healthy natural teeth
3. Inpatient or
outpatient hospitaliz -
ation and anesthesia
charges for medically
necessary dental
services provided to a
covered person who is
a child under age five
(5), is severely
disabled, or has a
medical condition that
requires hospital -
ization or general
anesthesia for dental
treatment, as determ -
ined by the medical
Claims Administrator.
Participating
Provider/In-
Network
Coinsurance²
Non-
Participating
Provider/Outof-Network
Coinsurance² Special Notes
You pay 25% You pay 45% Coverage only for reconstructive surgery that is incidental to or
follows surgery resulting from injury, sickness, or other diseases of the
involved body part; reconstructive surgery performed on a dependent
child because of congenital disease or anomaly that has resulted in a
functional defect as determined by the attending physician; or
treatment of cleft lip and palate for a dependent child under age 19. See
“Cleft Lip and Palate” in this chart.
You pay 25%
You pay 25%
You pay 25%
You pay 45%
You pay 45%
You pay 45%
Panniculectomy covered when both chronic, recurrent infection is
documented and interference with hygiene and activities of daily living
are documented.
No coverage for psychological or emotional reasons. No coverage for
repair of scars and blemishes on skin surfaces or cosmetic,
reconstructive or plastic surgery for any other purpose. Refer to “The
Women’s Health and Cancer Rights Act of 1998” section in this SPD
for mastectomy with reconstructive surgery.
No coverage for actual dental treatments that may be performed as part
of services (1), (2), or (3) shown to the left. Such dental treatments
include dental implants and prostheses, osteotomies and other
procedures associated with fitting of dentures or dental implants, root
canals, removal of impacted teeth or tooth root. Also see “TMJ
Services” in this chart.
Accidents or injuries sustained prior to the effective date of coverage
are eligible as coverage is based on actual date of treatment and not the
date the accident or injury occurred. Chewing injuries to teeth not
covered. Dental caries (cavities) not covered.
See “Hospital Inpatient Services” in this chart. Covered only when
related to a medical condition and necessary to protect and safeguard
the life of the patient.
¹ Refer to the “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits” section in this SPD to see if
any action is recommended or required on your part before receiving the service.
² The percentage in this column is based on the BCBS allowed amount. All coinsurance amounts (unless otherwise noted) are
paid after the deductible has been satisfied. Refer to the “Health Care Option Summary” section in this SPD for the deductible
information related to your health care option.
31

Retiree Health Care SPD Effective January 1, 2012
Early Retiree Medical Option, continued
Participating
Non-
Participating
Provider/In- Provider/Out-
Network of-Network
Service¹
Coinsurance² Coinsurance² Special Notes
DNA Analysis You pay 25% You pay 45% Genetic testing covered for the following indications only:
• To enable those affected by inherited disorders to make informed
choices about future reproduction;
• To detect breast, colon, or ovarian cancer in persons who have two
first-degree relatives with a history of these cancers. Only one firstdegree
relative is required for persons with a family history of premenopausal
breast or ovarian cancer or colon cancer diagnosed before
age 50; or
• To verify a diagnosis when specific pre-clinical evidence is present.
Durable Medical
Equipment (DME) and
Medical Supplies
Emergency Room
Care
You pay 25% You pay 45%
You pay 25%
after $150 ER
copay
You pay 25%
after $150 ER
copay
All other genetic testing and counseling is not covered.
Covered DME and Medical Supplies (including disposable) must be
prescribed by a physician and medically necessary for treatment of an
illness or injury.
Coverage includes DME such as: wheelchairs, ventilators, oxygen and
equipment, and side rails; stockings, and casts; insulin pumps,
glucometers and related equipment and devices; prosthetics, including
breast, artificial limbs and eyes required as the result of a congenital
defect, injury or illness; liquid nutrition (including amino acid-based
elemental formula) when recommended by a physician; IUDs; SADD
lights; implants; scalp hair prosthesis (wigs) for alopecia areata only (see
limitations that follow); and custom foot orthoses (see limitations that
follow).
Limitations:
• Wigs are covered for the medical condition of Alopecia Areata only
and limited to $350 paid by the plan per plan year.
• Custom foot orthoses limited to $500 paid by the plan per plan year.
• No coverage for over-the-counter products and items.
• DME and Supplies are covered up to the BCBS allowed amounts to
rent or buy item.
Syringes, test strips, lancets and needles are covered by Medco, not
BCBS. See the “Pharmacy” section in this SPD for more
information.
The copayment will be waived if an inpatient admission occurs for the
same condition within 24 hours.
Refer to the “Emergency Care” section in this SPD.
Enteral Nutrition
(tube feeding)
You pay 25% You pay 45%
Pharmaceuticals given to you while in the Emergency Room will be
covered under this benefit by BCBS, not Medco. If you are given a
written prescription to be filled at the time you leave the Emergency
Room, it will be covered by Medco, not BCBS. See the “Pharmacy”
section in this SPD for more information.
Covered when sole source of nutrition or inborn error of metabolism.
Eyeglasses or
You pay 25% You pay 45% Covered only for the medical conditions keratoconus and ulcerative
Contact Lenses
keratitis and post-cataract surgery (aphakia), accidental injury, or as a
therapeutic bandage. Limited to one pair of eyeglasses or contact lenses
after surgery paid by the plan. Thereafter, coverage applies only to lens
replacement if prescription changes.
¹ Refer to the “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits” section in this SPD to see if
any action is recommended or required on your part before receiving the service.
² The percentage in this column is based on the BCBS allowed amount. All coinsurance amounts (unless otherwise noted) are
paid after the deductible has been satisfied. Refer to the “Health Care Option Summary” section in this SPD for the deductible
information related to your health care option.
32

Retiree Health Care SPD Effective January 1, 2012
Early Retiree Medical Option, continued
Service¹
Hearing Aids and
Tests for Hearing
Aids
Home Health Care
Home Infusion
Therapy
Participating
Provider/In-
Network
Coinsurance²
Non-
Participating
Provider/Outof-Network
Coinsurance² Special Notes
You pay 25% You pay 45% Hearing aids are covered for a dependent child under age 13 who has a
hearing loss due to a congenital loss of hearing that cannot be corrected by
other covered procedures. Coverage is limited to $1,000 paid by the
plan per ear every third plan year and includes the hearing aid, dispensing
fee, molds, impressions, batteries and repairs. Replacements are not
covered if lost.
You pay 25% You pay 45%
No coverage for tests for hearing aids.
To be covered, skilled care must be prescribed by a physician and
provided by a Medicare approved or other pre-approved licensed
home health agency. Coverage is limited to $15,000 paid by the plan per
plan year. $15,000 limit does not include lab and x-ray charges, drugs or
Durable Medical Equipment purchased through home health care provider.
See “Durable Medical Equipment (DME) and Medical Supplies” in this
chart. Services for custodial care, non-skilled care, services of a nonmedical
nature, private duty nursing, rest cures and mental health are not
covered.
You pay 25% You pay 45% To be covered, care must be ordered by a physician and provided by a
Medicare approved or other pre-approved licensed home health
agency. Covered services include solutions and pharmaceutical additives,
pharmacy compounding and dispensing services, durable medical
equipment and supplies, nursing services to train you or your caregiver to
monitor your therapy, and collection, analysis and reporting of lab tests.
Infusion services do not apply to the Home Health Care maximum.
Hospice Care You pay 25% You pay 45% Hospice care for terminally ill patients provided by a Medicare-certified
hospice provider or other pre-approved hospice.
Coverage for inpatient and outpatient hospital care, routine and continuous
home nursing care, home health aide visits, physical therapy, speech
therapy, language therapy, occupational therapy, social worker visits,
dietary/nutritional counseling, durable medical equipment, routine medical
supplies and other supportive services provided to meet the physical,
psychological, spiritual, and social needs of the dying patient.
Coverage includes patient care instructions, respite care and other
supportive services for the family, both before and after the death of the
patient.
Coverage for respite care is limited to 10 days paid by the plan during the
episode of hospice care. To be eligible for hospice care, a physician must
document that according to best medical judgment, the patient has six
months or less to live, and the patient/family must agree not to pursue
curative treatment. Inpatient care in a hospice or hospital is covered
under Hospital Inpatient Services. Take-home drugs will process under
this benefit level. Medical care services unrelated to the terminal illness
may be covered according to other Plan benefits and requirements.
Eligible services provided by a skilled nursing facility are covered but are
separate from the hospice benefit. (See Skilled Nursing under “Hospital
Inpatient Services” in this chart.)
¹ Refer to the “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits” section in this SPD to see if
any action is recommended or required on your part before receiving the service.
² The percentage in this column is based on the BCBS allowed amount. All coinsurance amounts (unless otherwise noted) are
paid after the deductible has been satisfied. Refer to the “Health Care Option Summary” section in this SPD for the deductible
information related to your health care option.
33

Retiree Health Care SPD Effective January 1, 2012
Early Retiree Medical Option, continued
Service¹
Hospital Inpatient
Services
1. Hospital Services
2. Acute
Rehabilitation (not
nursing home)
3. Skilled Nursing
Facility (not nursing
home)
Hospital
Outpatient
Services
1. Hospital Services
2. Ambulatory
Surgery Centers
Infertility
Treatment
Participating
Provider/In-
Network
Coinsurance²
You pay 25%
You pay 25%
You pay 25%
You pay 25%
You pay 25%
Non-
Participating
Provider/Outof-Network
Coinsurance² Special Notes
You pay 25%
You pay 25%
You pay 45%
You pay 45%
You pay 45%
You pay 25% You pay 45%
For Mental Health and Substance Abuse Coverage, refer to that section in
this SPD. See the “Knee and Hip Replacements” and “Spine Surgery”
sections in this SPD for more information.
Coverage is provided for up to 365 hospital days per plan year, including a
semiprivate room, meals, general nursing care, intensive and other special
care units, ancillary services and supplies such as operating, recovery, and
treatment rooms, supplies, in-hospital and take-home drugs. Private room
is covered only when medically necessary or at the allowable charges for
an average semiprivate room. Patient convenience items and private duty
nursing are not covered.
Acute Rehabilitation services covered when services are expected to make
measurable or sustainable improvement within a reasonable amount of
time.
Skilled nursing must be ordered by a physician and be medically
necessary. Skilled nursing facility limited to 100 days paid by the plan per
plan year. Semiprivate room, meals, general nursing care, ancillary
services and supplies, and in-facility drugs are covered. Private room is
covered only when medically necessary or at the allowable charges for an
average semiprivate room. Patient convenience items, custodial care and
private duty nursing are not covered.
Coverage for scheduled surgery, radiation, chemotherapy, kidney dialysis,
respiratory therapy, diabetes outpatient self-management training and
education which includes medical nutrition therapy, and all other eligible
outpatient hospital care.
See the “Knee and Hip Replacements” and “Spine Surgery” sections in
this SPD for more information.
A $2,500 lifetime maximum paid by the Program per family (not per
person) will apply to all infertility services, including medical and
surgical treatment.
A separate $7,500 lifetime maximum paid by the Program per family
(not per person) will apply to all infertility prescription drugs. See the
“Pharmacy” section in this SPD.
Coverage is provided for infertility testing and treatment due to the
absence of fallopian tubes, a diagnosis of irreparably damaged fallopian
tubes due to disease or natural blockage, and low sperm count.
Not covered: Sperm banking, donor ova or sperm, post tubal ligation or
post sterilization reversal, charges for procedures which facilitate a
pregnancy but do not treat the cause of infertility, such as in-vitro
fertilization (IF, IVF), artificial insemination (AI), intrauterine
insemination (IUI), embryo transfer, gamete intrafallopian transfer (GIFT),
zygote intrafallopian transfer and tubal ovum transfer, services for or
related to assisted reproductive technology (ART) procedures, and
surrogate pregnancy and related charges.
Contact BCBS for more information.
¹ Refer to the “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits” section in this SPD to see if
any action is recommended or required on your part before receiving the service.
² The percentage in this column is based on the BCBS allowed amount. All coinsurance amounts (unless otherwise noted) are
paid after the deductible has been satisfied. Refer to the “Health Care Option Summary” section in this SPD for the deductible
information related to your health care option.
34

Retiree Health Care SPD Effective January 1, 2012
Early Retiree Medical Option, continued
Service¹
Lab, X-ray, CT
Scans, MRI and
Nuclear Imaging
1. Illness-Related
2. Preventive Care
Mastectomy and
Reconstructive
Surgery
Maternity
1. Hospital
Services (Inpatient
or Outpatient) and
Postpartum Office
Visits
2. Prenatal Office
Visits
Participating
Provider/In-
Network
Coinsurance²
You pay 25%
The Program
pays 100%
(no
deductible)
Non-
Participating
Provider/Outof-Network
Coinsurance² Special Notes
See “Maternity” in this chart for prenatal lab and x-ray services.
You pay 45%
Not covered
by the
Program
Services are paid based on the billing codes used by your provider on the
claim submitted to the medical Claims Administrator for payment.
If a non-participating/out-of-network provider performs the procedure
and then sends it out to be read, the charges for the reading only will be
paid at the participating/in-network level.
When submitted with an illness diagnosis code.
See the “Preventive Care” section in this SPD for more information.
You pay 25% You pay 45% See special notice in the section “The Woman’s Health and Cancer
Rights Act of 1998” in this SPD.
You pay 25%
The Program
pays 100%
(no
deductible)
You pay 45%
You pay 45%
Coverage is the same as for illness. Pregnancy coverage ends when your
coverage under your plan otherwise ends for any reason. New
dependents must be added within 60 days of birth to be covered (see
the “Eligibility and Enrollment section” section in this SPD).
Inpatient benefits will not be restricted to less than 48 hours from the
time of vaginal delivery or 96 hours from the time of Cesarean section
delivery. Refer to the “Inpatient Maternity Care” section in this SPD for
further details. You are allowed one home health visit upon discharge.
(See “Home Health Care” in this chart for additional information.)
Prenatal lab and x-ray services are paid based on where the services are
performed. If in a facility, they will pay under the Hospital Services
benefit. If in an office, they will pay under the Prenatal Office Visits
benefit.
No coverage for adoption or adoption-related expenses, surrogate
pregnancy or related expenses, childbirth classes, or delivery at home.
Mental Health You pay 25% You pay 45% See the “Mental Health and Substance Abuse Coverage” section in this
Nutritional
Counseling
Orthoptic Training
(Eye muscle
exercise)
SPD for more details.
You pay 25% You pay 45% Covered when provided by a registered dietician to develop a dietary
treatment plan to treat and/or manage medical conditions that require a
special diet (e.g., anorexia, diabetes, gout, etc.).
You pay 25% You pay 45%
No coverage for non-disease specific counseling, nutritional education
such as general good eating habits, calorie control or dietary preferences.
Training must be provided by a licensed optometrist or an orthoptic
technician.
¹ Refer to the “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits”, section in this SPD to see if
any action is recommended or required on your part before receiving the service.
² The percentage in this column is based on the BCBS allowed amount. All coinsurance amounts (unless otherwise noted) are
paid after the deductible has been satisfied. Refer to the “Health Care Option Summary” section in this SPD for the deductible
information related to your health care option.
35

Retiree Health Care SPD Effective January 1, 2012
Early Retiree Medical Option, continued
Service¹
Orthoses —
Custom Only
(Custom-made
Orthopedic Shoes,
Arch Supports and
Foot Orthoses)
Osteopaths
Physical,
Occupational
and Speech
Therapy
Physician/
Professional
Services
2. Vasectomy
Participating
Provider/In-
Network
Coinsurance²
Non-
Participating
Provider/Outof-Network
Coinsurance² Special Notes
You pay 25% You pay 45% Coverage limited to $500 paid by the Program per plan year.
No coverage for over-the-counter products.
You pay 25% You pay 45% If receiving physical therapy or chiropractic services, refer to those
specific services in this chart for benefits.
You pay 25% You pay 45% Limited to 50 visits (in outpatient or office setting) paid by the plan per
plan year for physical and occupational therapy combined unless
additional visits are deemed medically necessary.
You pay 25%
You pay 25%
You pay 45%
Not covered
by the
Program
Limited to 25 visits (in outpatient or office setting) paid by the plan per
plan year for speech therapy unless additional visits are deemed
medically necessary.
No coverage for services primarily educational in nature, vocational
rehabilitation, developmental delay services, self-care and self-help
training (non-medical), health clubs and spas, learning disabilities and
disorders, and recreational therapy or for services not expected to make
measurable or sustainable improvement within a reasonable amount of
time.
Any written prescription written by your provider to be filled at a
pharmacy will be covered by Medco, not BCBS. See the “Pharmacy”
section in this SPD for more information.
Pregnancy and
Prenatal Care
Benefits listed also include visits to convenience clinics such as
MinuteClinic, Take Care or RediClinic.
See “Maternity” in this chart.
Prescription Drugs See the “Pharmacy” section in this SPD.
Preventive Care The Program Not covered See the “Preventive Care” section in this SPD for more information.
pays 100% by the
(no
deductible)
Program
Sleep Studies You pay 25% Not covered No coverage for unattended sleep studies, medically appropriate sleep
by the studies if done at patient’s home, SNAP studies or for overnight pulse
Program oximetry to screen patients for sleep apnea.
Sterilization
See “Physician/Professional Services,” “Hospital Inpatient Services,” or
“Hospital Outpatient Services” in this chart for related services.
1. Tubal Ligation You pay 25% Not covered
by the
Program
Supplies
See “Durable Medical Equipment (DME) and Medical Supplies” in this
chart. Syringes, test strips, lancets and needles are covered by Medco,
not BCBS. See the “Pharmacy” section in this SPD for more
information.
¹ Refer to the “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits” section in this SPD to see if
any action is recommended or required on your part before receiving the service.
² The percentage in this column is based on the BCBS allowed amount. All coinsurance amounts (unless otherwise noted) are
paid after the deductible has been satisfied. Refer to the “Health Care Option Summary” section in this SPD for the deductible
information related to your health care option.
36

Retiree Health Care SPD Effective January 1, 2012
Early Retiree Medical Option, continued
Service¹
Participating
Provider/In-
Network
Coinsurance²
Non-
Participating
Provider/Outof-Network
Coinsurance² Special Notes
TMJ Services You pay 25% You pay 45% $5,000 lifetime maximum paid by plan per person for all related services,
including Orthognathic surgery. Related physical therapy services are
paid under the Physical Therapy benefit and do not apply to the TMJ
Transplants You pay 25% Not covered
by the
Program
Urgent Care You pay 25% You pay 45%
Weight Loss
Treatment
1. Age 18 and older
2. Under age 18
You pay 25%
You pay 25%
Not covered
by the
Program
You pay 45%
lifetime maximum.
See the “Transplants” section in this SPD for important coverage
information.
Coverage is limited to bariatric surgery for severe and morbid obesity.
Coverage limited for Panniculectomy. See “Cosmetic, Reconstructive or
Plastic Surgery” in this chart as well as the “Bariatric Surgery” section in
this SPD for important coverage information and requirements.
No coverage for weight loss and diet programs of any type.
¹ Refer to the “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits” section in this SPD to see if
any action is recommended or required on your part before receiving the service.
² The percentage in this column is based on the BCBS allowed amount. All coinsurance amounts (unless otherwise noted) are
paid after the deductible has been satisfied. Refer to the “Health Care Option Summary” section in this SPD for the deductible
information related to your health care option.
37

Retiree Health Care SPD Effective January 1, 2012
Comprehensive Option
All benefit payments are based on the BCBS allowed amounts. Although this option does not have a BCBS network,
if you use participating BCBS providers, you generally will not be responsible for payment of charges in excess of
the BCBS allowed amount. Please note that eligible services are covered at 80% of the allowed amount regardless if
the provider is participating or non-participating for retirees that are enrolled in Medicare Part A and Medicare Part
B. If a service is not listed, it is likely not a covered service. Please call BCBS of MN if you have questions about
coverage for a specific procedure. Telephone numbers are listed in the “Important Resources” section of this SPD.
Service 1
Participating
Provider After
Deductible
Coinsurance 2
Non-
Participating
Provider After
Deductible
Coinsurance 2 Special Notes
Acupuncture You pay 20% You pay 40% Coverage is limited to pain management only and services must be
provided as part of a comprehensive pain management program after all
other treatment options have failed. Coverage also provided for
prevention and treatment of nausea associated with surgery,
chemotherapy or pregnancy.
Allergy Testing
and Treatment
You pay 20% You pay 40%
No coverage for therapeutic acupuncture, weight loss management,
smoking cessation or other non-listed purposes.
Coverage provided for testing, serum, and allergy shots.
Ambulance You pay 20% You pay 40% Coverage is limited to air or ground transportation from the place of
departure to the nearest facility equipped to treat the illness, and to
prearranged medically necessary air or ground ambulance transportation
requested by an attending physician or nurse. If BCBS of MN
determines air ambulance was not medically necessary but ground
ambulance would have been medically necessary, the Program pays up
to the BCBS of MN allowed amount for ground ambulance.
Benefit
You pay 20% You pay 40% If the benefit substitution of treatment is a prescription drug, see the
Substitution
section “Pharmacy” in this SPD.
Chemical
Dependency/
Substance Abuse
Chiropractic
Services
Cleft Lip and
Palate
Cosmetic,
Reconstructive or
Plastic Surgery
Benefit substitution is a course of treatment approved and authorized by
a BCBS case manager as an alternative to the services and supplies that
would otherwise have been covered by the Program. The benefit
substitution must be at a cost equal to or lower than that of the care
being provided and maintain the same quality of care. Failure to follow
an approved treatment plan may result in nonpayment of services. Call
the customer service number on your ID card for further information.
See the “Mental Health and Substance Abuse Coverage” section in this
SPD for more details.
You pay 20% You pay 40% Limited to 25 visits paid by the option per plan year.
You pay 20% You pay 40% Coverage only provided for a dependent child under age 19. Dental
implants and orthodontia services provided as part of the treatment
would be eligible.
You pay 20% You pay 40% Coverage only for reconstructive surgery that is incidental to or follows
surgery resulting from injury, sickness, or other diseases of the involved
body part; reconstructive surgery performed on a dependent child
because of congenital disease or anomaly that has resulted in a
functional defect as determined by the attending physician; or treatment
of cleft lip and palate for a dependent child under age 19. See "Cleft Lip
and Palate" in this chart.
Continued on next page
¹ Refer to the “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits” section in this SPD to see if
any action is recommended or required on your part before receiving the service.
² The percentage in this column is based on the BCBS allowed amount. All coinsurance amounts (unless otherwise noted) are
paid after the deductible has been satisfied. Refer to the “Health Care Option Summary” section in this SPD for the deductible
information related to your health care option.
38

Retiree Health Care SPD Effective January 1, 2012
Comprehensive Option, continued
Service 1
Cosmetic,
Reconstructive or
Plastic Surgery,
continued
Dental-Related
Services
Dental services
covered under the
U.S. Bank Retiree
Health Care
Program are limited
to:
1. Treatment of
fractured jaw
2. Accident-related
dental services from
a physician or
dentist for the
treatment of an
injury to sound and
healthy natural teeth
3. Inpatient or
outpatient
hospitalization and
anesthesia charges
for medically
necessary dental
services provided to
a covered person
who is a child under
age five (5); is
severely disabled;
or has a medical
condition that
requires
hospitalization or
general anesthesia
for dental treatment,
as determined by
the medical Claims
Administrator.
Participating
Provider After
Deductible
Coinsurance 2
Non-
Participating
Provider After
Deductible
Coinsurance 2 Special Notes
You pay 20% You pay 40% Panniculectomy covered when both chronic, recurrent infection is
documented and interference with hygiene and activities of daily living
are documented.
You pay 20%
You pay 20%
You pay 20%
You Pay 40%
You Pay 40%
You Pay 40%
No coverage for psychological or emotional reasons. No coverage for
repair of scars and blemishes on skin surfaces or cosmetic, reconstructive
or plastic surgery for any other purpose. Refer to “The Women’s Health
and Cancer Rights Act of 1998” section in this SPD for mastectomy with
reconstructive surgery.
No coverage for actual dental treatments that may be performed as part
of services in (1), (2) or (3) shown to the left. Such dental treatments
include dental implants and prostheses, osteotomies and other procedures
associated with fitting of dentures or dental implants, root canals,
removal of impacted teeth or tooth root. Also see the section “TMJ
Services” in this chart.
Accidents or injuries sustained prior to the effective date of coverage are
eligible as coverage is based on actual date of treatment and not the date
the accident or injury occurred. Chewing injuries to teeth not covered.
Dental caries (cavities) not covered.
See “Hospital Inpatient Services” in this chart. Covered only when
related to a medical condition and necessary to protect and safeguard the
life of the patient.
¹ Refer to the “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits” section in this SPD to see if
any action is recommended or required on your part before receiving the service.
² The percentage in this column is based on the BCBS allowed amount. All coinsurance amounts (unless otherwise noted) are
paid after the deductible has been satisfied. Refer to the “Health Care Option Summary” section in this SPD for the deductible
information related to your health care option.
39

Retiree Health Care SPD Effective January 1, 2012
Comprehensive Option, continued
Service 1
Participating
Provider After
Deductible
Coinsurance 2
DNA Analysis You pay 20%
Durable Medical
Equipment (DME)
and Medical
Supplies
Emergency Room
Care
Non-
Participating
Provider After
Deductible
Coinsurance 2 Special Notes
You pay 40% Genetic testing covered for the following indications only:
• To enable those affected by inherited disorders to make informed
choices about future reproduction;
• To detect breast, colon, or ovarian cancer in persons who have two
first-degree relatives with a history of these cancers. Only one firstdegree
relative is required for persons with a family history of premenopausal
breast or ovarian cancer or colon cancer diagnosed before
age 50; or
• To verify a diagnosis when specific pre-clinical evidence is present.
You pay 20% You pay 40%
All other genetic testing and counseling is not covered.
Covered DME and medical supplies (including disposable) must be
prescribed by a physician and medically necessary for treatment of an
illness or injury.
You pay 20%
after $100 ER
copay
You pay 40%
after $100 ER
copay
Coverage includes DME such as: wheelchairs, ventilators, oxygen and
equipment, and side rails; stockings, and casts; insulin pumps,
glucometers and related equipment and devices; prosthetics, including
breast, artificial limbs and eyes required as the result of a congenital
defect, injury or illness; liquid nutrition (including amino acid-based
elemental formula) when recommended by a physician; IUDs; SADD
lights; implants; scalp hair prosthesis (wigs) for alopecia areata only (see
limitations that follow); and custom foot orthoses (see limitations that
follow).
Limitations:
• Wigs are covered for the medical condition of Alopecia Areata only
and limited to $350 paid by the plan per plan year.
• Custom foot orthoses limited to $500 paid by the plan per plan year.
• No coverage for over-the-counter products and items.
• DME and Supplies are covered up to the BCBS allowed amounts to
rent or buy item.
Syringes, test strips, lancets and needles are covered by Medco, not
BCBS. See the “Pharmacy” section in this SPD for more information.
The copayment will be waived if inpatient admission occurs for the same
condition within 24 hours.
Refer to “Emergency Care” in this SPD.
Enteral Nutrition
(tube feeding)
You pay 20% You pay 40%
Pharmaceuticals given to you while in the Emergency Room will be
covered under this benefit by BCBS not Medco. If you are given a
written prescription to be filled at the time you leave the Emergency
Room, it will be covered by Medco, not BCBS. See the “Pharmacy”
section in this SPD for more information.
Covered when sole source of nutrition or inborn error of metabolism.
Eyeglasses or You pay 20% You pay 40% Covered only for the medical conditions keratoconus and ulcerative
Contact Lenses
keratitis and post-cataract surgery (aphakia), accidental injury, or as a
therapeutic bandage. Limited to one pair of eyeglasses or contact lenses
after surgery paid by the Program. Thereafter, coverage applies only to
lens replacement if prescription changes.
¹ Refer to the “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits” section in this SPD to see if
any action is recommended or required on your part before receiving the service.
² The percentage in this column is based on the BCBS allowed amount. All coinsurance amounts (unless otherwise noted) are
paid after the deductible has been satisfied. Refer to the “Health Care Option Summary” section in this SPD for the deductible
information related to your health care option.
40

Retiree Health Care SPD Effective January 1, 2012
Comprehensive Option, continued
Service 1
Hearing Aids and
Tests for Hearing
Aids
Participating
Provider After
Deductible
Coinsurance 2
Non-
Participating
Provider After
Deductible
Coinsurance 2 Special Notes
You pay 20% You pay 40% Hearing aids are covered for a dependent child under age 13 who has a
hearing loss due to a congenital loss of hearing that cannot be corrected
by other covered procedures. Coverage is limited to $1,000 paid by the
Program per ear every third plan year and includes the hearing aid,
dispensing fee, molds, impressions, batteries and repairs. Replacements
are not covered if lost.
No coverage for tests for hearing aids.
Home Health Care You pay 20% You pay 40% To be covered, skilled care must be prescribed by a physician and
provided by a Medicare approved or other pre-approved licensed
home health agency. Coverage is limited to $15,000 per year. $15,000
limit does not include lab and x-ray charges, drugs or Durable Medical
Equipment purchased through home health care provider.
Home Infusion
Therapy
See “Durable Medical Equipment (DME) and Medical Supplies” section
of this chart. Services for custodial care, non-skilled care, services of a
non-medical nature, private duty nursing, rest cures and mental health are
not covered.
You pay 20% You pay 40% To be covered, care must be ordered by a physician and provided by a
Medicare approved or other pre-approved licensed home health
agency. Covered services include solutions and pharmaceutical additives,
pharmacy compounding and dispensing services, durable medical
equipment and supplies, nursing services to train you or your caregiver to
monitor your therapy, and collection, analysis and reporting of lab tests.
Infusion services do not apply to the Home Health Care maximum.
Hospice Care You pay 20% You pay 40% Hospice care for terminally ill patients provided by a Medicare certified
hospice provider or other pre-approved hospice.
Coverage for inpatient and outpatient hospital care, routine and
continuous home nursing care, home health aide visits, physical therapy,
speech therapy, language therapy, occupational therapy, social worker
visits, dietary/nutritional counseling, durable medical equipment, routine
medical supplies and other supportive services provided to meet the
physical, psychological, spiritual, and social needs of the dying patient.
Coverage includes patient care instructions respite care and other
supportive services for the family, both before and after the death of the
patient.
Coverage for respite care is limited to 10 days paid by the Program during
the episode of hospice care. To be eligible for hospice care, a physician
must document that according to best medical judgment, the patient has
six months or less to live, and the patient/family must agree not to pursue
curative treatment. Inpatient care in a hospice or hospital is covered
under Hospital Inpatient Services. Take-home drugs will process under
this benefit level.
Medical care services unrelated to the terminal illness may be covered
according to other Program benefits and requirements.
Eligible services provided by a skilled nursing facility are covered but are
separate from the hospice benefit. (See Skilled Nursing under “Hospital
Inpatient Services” in this chart.)
¹ Refer to the “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits” section in this SPD to see if
any action is recommended or required on your part before receiving the service.
² The percentage in this column is based on the BCBS allowed amount. All coinsurance amounts (unless otherwise noted) are
paid after the deductible has been satisfied. Refer to the “Health Care Option Summary” section in this SPD for the deductible
information related to your health care option.
41

Retiree Health Care SPD Effective January 1, 2012
Comprehensive Option, continued
Service 1
Hospital Inpatient
Services
1. Hospital Services
2. Acute
Rehabilitation (not
nursing home)
3. Skilled Nursing
Facility (not
nursing home)
Hospital
Outpatient
Services
1. Hospital
Services
2. Ambulatory
Surgery Centers
Infertility
Treatment
Participating
Provider After
Deductible
Coinsurance 2
You pay 20%
You pay 20%
You pay 20%
You pay 20%
You pay 20%
Non-
Participating
Provider After
Deductible
Coinsurance 2 Special Notes
You pay 40%
You pay 40%
You pay 40%
You pay 40%
You pay 40%
For Mental Health and Substance Abuse coverage, refer to that
section in this SPD. See the “Knee and Hip Replacements” and
“Spine Surgery” sections in this SPD for more information.
Coverage is provided for up to 365 hospital days per plan year,
including a semiprivate room, meals, general nursing care, intensive
and other special care units, ancillary services and supplies such as
operating, recovery, and treatment rooms, supplies, and in-hospital
and take-home drugs. Private room is covered only when medically
necessary or at the allowable charges for an average semiprivate
room. Patient convenience items and private duty nursing are not
covered.
Acute Rehabilitation services covered when services are expected to
make measurable or sustainable improvement within a reasonable
amount of time.
Skilled nursing must be ordered by a physician and be medically
necessary. Skilled nursing facility limited to 100 days paid by the
Program per plan year. Semiprivate room, meals, general nursing
care, ancillary services and supplies, and in-facility drugs are covered.
Private room is covered only when medically necessary or at the
allowable charges for an average semiprivate room. Patient
convenience items, custodial care and private duty nursing are not
covered.
Coverage for scheduled surgery, radiation, chemotherapy, kidney
dialysis, respiratory therapy, diabetes outpatient self-management
training and education which includes medical nutrition therapy, and
all other eligible outpatient hospital care.
See the “Knee and Hip Replacements” and “Spine Surgery” sections
in this SPD for more information.
You pay 20% You pay 40% A $2,500 lifetime maximum paid by the Program per family (not
per person) will apply to all infertility services, including medical
and surgical treatment.
A separate $7,500 lifetime maximum paid by the Program per
family (not per person) will apply to all infertility prescription
drugs. See the “Pharmacy” section in this SPD.
Coverage is provided for infertility testing and treatment due to the
absence of fallopian tubes, a diagnosis of irreparably damaged
fallopian tubes due to disease or natural blockage, and low sperm
count.
Continued on next page
¹ Refer to the “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits” section in this SPD to see if
any action is recommended or required on your part before receiving the service.
² The percentage in this column is based on the BCBS allowed amount. All coinsurance amounts (unless otherwise noted) are
paid after the deductible has been satisfied. Refer to the “Health Care Option Summary” section in this SPD for the deductible
information related to your health care option.
42

Retiree Health Care SPD Effective January 1, 2012
Comprehensive Option, continued
Service 1
Infertility
Treatment,
continued
Lab, X-ray, CT
Scans, MRI and
Nuclear Imaging
1. Illness-Related
2. Preventive Care
Mastectomy and
Reconstructive
Surgery
Maternity
1. Hospital
Services (Inpatient
or Outpatient) and
Postpartum Visits
2. Prenatal Office
Visits
Participating
Provider After
Deductible
Coinsurance 2
You pay 20%
The Program
pays 100% (no
deductible)
Non-
Participating
Provider After
Deductible
Coinsurance 2 Special Notes
You pay 40%
Not covered by
the Program
Not covered: Sperm banking, donor ova or sperm, post tubal ligation
or post sterilization reversal, charges for procedures which facilitate a
pregnancy but do not treat the cause of infertility, such as in-vitro
fertilization (IF, IVF), artificial insemination (AI), intrauterine
insemination (IUI), embryo transfer, gamete intrafallopian transfer
(GIFT), zygote intrafallopian transfer and tubal ovum transfer, services
for or related to assisted reproductive technology (ART) procedures,
and surrogate pregnancy and related charges.
Contact BCBS of MN for more information.
See the “Maternity” section in this chart for prenatal lab and x-ray
services.
Services are paid based on the billing codes used by your provider on
the claim submitted to the medical Claims Administrator for payment.
If a non-participating provider performs the procedure and then sends
it out to be read, the charges for the reading only will be paid at the
participating level.
When submitted with an illness diagnosis code.
See the “Preventive Care” section in this SPD for more information.
You pay 20% You pay 40% See special notice in the section “The Woman’s Health and Cancer
Rights Act of 1998” in this SPD..
You pay 20%
The Program
pays 100% (no
deductible)
You pay 40%
You pay 40%
Coverage is the same as for illness. Pregnancy coverage ends when
your coverage under your option otherwise ends for any reason. New
dependents must be added within 60 days of birth to be covered.
(See the applicable “Eligibility and Enrollment section” in this SPD.)
Inpatient benefits will not be restricted to less than 48 hours from the
time of vaginal delivery or 96 hours from the time of Caesarean
section delivery. Refer to the “Inpatient Maternity Care” section in this
SPD for further details. You are allowed one home health visit upon
discharge. (See “Home Health Care” section in this chart for additional
information.)
Prenatal lab and x-ray services are paid based on where the services
are performed. If in a facility, they will pay under the Hospital
Services benefit. If in an office, they will pay under the Prenatal Office
Visits benefit.
No coverage for adoption or adoption-related expenses, surrogate
pregnancy or related expenses, childbirth classes, or delivery at home.
Mental Health See the “Mental Health and Substance Abuse Coverage” section in this
SPD for more details.
¹ Refer to the “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits” section in this SPD to see if
any action is recommended or required on your part before receiving the service.
² The percentage in this column is based on the BCBS allowed amount. All coinsurance amounts (unless otherwise noted) are
paid after the deductible has been satisfied. Refer to the “Health Care Option Summary” section in this SPD for the deductible
information related to your health care option.
43

Retiree Health Care SPD Effective January 1, 2012
Comprehensive Option, continued
Service 1
Nutritional
Counseling
Orthoptic Training
(Eye muscle
exercise)
Orthoses —
Custom Only
(Custom-made
Orthopedic Shoes,
Arch Supports and
Foot Orthoses)
Osteopaths
Physical,
Occupational
and Speech
Therapy
Physician/
Professional
Services
Participating
Provider After
Deductible
Coinsurance 2
Non-
Participating
Provider After
Deductible
Coinsurance 2 Special Notes
You pay 20% You pay 40% Covered when provided by a registered dietician to develop a dietary
treatment plan to treat and/or manage medical conditions that require a
special diet (e.g., anorexia, diabetes, gout, etc.).
No coverage for non-disease specific counseling, nutritional education
such as general good eating habits, calorie control or dietary
preferences.
You pay 20% You pay 40% Training must be provided by a licensed optometrist or an orthoptic
technician.
You pay 20% You pay 40% Coverage limited to $500 paid by the Program per plan year.
No coverage for over-the-counter products.
You pay 20% You pay 40% If receiving physical therapy or chiropractic services, refer to those
specific services in this chart for benefits.
You pay 25% You pay 45% Limited to 50 visits (in outpatient or office setting) paid by the plan per
plan year for physical and occupational therapy combined unless
additional visits are deemed medically necessary.
Limited to 25 visits (in outpatient or office setting) paid by the plan per
plan year for speech therapy unless additional visits are deemed
medically necessary.
No coverage for services primarily educational in nature, vocational
rehabilitation, developmental delay services, self-care and self-help
training (non-medical), health clubs and spas, learning disabilities and
disorders, and recreational therapy or for services not expected to make
measurable or sustainable improvement within a reasonable amount of
time.
You pay 20% You pay 40% Any written prescription written by your provider to be filled at a
pharmacy will be covered by Medco, not BCBS. See the “Pharmacy”
section in this SPD for more information.
Pregnancy and
Prenatal Care
Clinical Visits
Benefits listed also include visits to convenience clinics such as
MinuteClinic, Take Care or RediClinic.
See “Maternity” in this chart.
Prescription Drugs See the “Pharmacy” section in this SPD.
Preventive Care The Program Not covered by See the “Preventive Care” section in this SPD for more information.
pays 100%(no
deductible)
the Program
Sleep Studies You pay 20% Not covered by No coverage for unattended sleep studies, medically appropriate sleep
the Program studies if done at patient’s home, SNAP studies or for overnight pulse
oximetry to screen patients for sleep apnea.
¹ Refer to the “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits” section in this SPD to see if
any action is recommended or required on your part before receiving the service.
² The percentage in this column is based on the BCBS allowed amount. All coinsurance amounts (unless otherwise noted) are
paid after the deductible has been satisfied. Refer to the “Health Care Option Summary” section in this SPD for the deductible
information related to your health care option.
44

Retiree Health Care SPD Effective January 1, 2012
Comprehensive Option, continued
Sterilization
1. Tubal Ligation
2. Vasectomy
Supplies
TMJ Services
You pay 20%
You pay 20%
Not covered by
the Program
Not covered by
the Program
See “Physician/Professional Services,” “Hospital Inpatient Services,”
or “Hospital Outpatient Services” in this chart for related services.
See “Durable Medical Equipment (DME) and Medical Supplies” in
this chart. Syringes, test strips, lancets and needles are covered by
Medco, not BCBS. See the “Pharmacy” section in this SPD for
more information.
You pay 20% You pay 40% $5,000 lifetime maximum paid by the Program per person for all
related services, including Orthognathic surgery. Related physical
therapy services are paid under the Physical Therapy benefit and do
Transplants You pay 20% Not covered by
the Program
Urgent Care
Weight Loss
Treatment
You pay 20% You pay 40%
1. Age 18 and older
2. Under age 18
You pay 20%
You pay 20%
Not covered by
the Program
You pay 40%
not apply to the TMJ lifetime maximum.
See the “Transplants” section later in this SPD for important coverage
information.
Coverage is limited to bariatric surgery for severe and morbid obesity.
Coverage limited for Panniculectomy. See “Cosmetic, Reconstructive
or Plastic Surgery” in this chart as well as the “Bariatric Surgery”
section in this SPD for important coverage information and
requirements.
No coverage for weight loss and diet programs of any type.
¹ Refer to the “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits” section in this SPD to see if
any action is recommended or required on your part before receiving the service.
² The percentage in this column is based on the BCBS allowed amount. All coinsurance amounts (unless otherwise noted) are
paid after the deductible has been satisfied. Refer to the “Health Care Option Summary” section in this SPD for the deductible
information related to your health care option.
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Retiree Health Care SPD Effective January 1, 2012
HOW COVERAGE WORKS IF YOU ARE UNDER
AGE 65 AND NOT MEDICARE ELIGIBLE
Read this section if you or any of your eligible dependents are under age 65 and not Medicare
eligible. If you have covered dependents age 65 or older or are pre-65 and Medicare eligible, also
read the section, “How Coverage Works If You Are Age 65 Or Older Or Pre-65 And Medicare
Eligible” and “Medicare Eligible Retirees And Dependents Turning Age 65.”
Note: If you are enrolled in Kaiser Colorado, this information does not apply to you. Please see
the separate Kaiser materials.
Which Network Providers to Use
Early Retiree Medical Option
This option lets you and your covered dependents choose where you receive eligible medical
services, including second opinions. If you use providers who participate in the BCBS BlueCard
PPO network, the Program pays a greater portion of the cost of covered services. The BCBS
BlueCard PPO network also applies to covered dependents not residing with you (such as noncustodial
dependents or dependents attending school away from home).
Blue Distinction Centers for Specialty Care ® – Select medical facilities that have been awarded
designation because they have demonstrated expertise in delivering quality health care, under
objective selection criteria. Except for transplants, Blue Distinction Centers are intended to treat
members age 18 and older. Although Blue Distinction Centers currently only exist for Bariatric
Surgery, Cardiac Care, Complex and Rare Cancers, Knee and Hip Replacements, Spine Surgery
and Transplants, additional centers may be added in the future. If new centers are added, they
can be found at http://www.bluecrossmn.com/usb.
In-network providers for BCBS are listed on the BCBS Web site* or are available by calling the
BCBS customer service department (see the “Important Resources” section in this SPD).
* Every effort is made to ensure that the list of providers on the BCBS Web site is up-to-date and accurate.
However, the network is subject to change throughout the year. It is your responsibility to verify that the provider
you or a covered family member uses is in the network associated with your health care option. You should call
BCBS’s customer service department or access their Web site before you receive care to find out if a specific
provider continues to be part of the network.
If you choose to receive covered treatment from a provider who is not in the BCBS network (an
out-of-network provider), you will pay a greater share of the cost. You are also responsible for
notifying BCBS prior to receiving certain services or being admitted to the hospital. (See the
section “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits,”
in this SPD for more information.) In addition, you may need to file your own claim. See “Filing
Health Care Claims – BCBS” in this SPD for more information.
When you use “out-of-network,” but “participating” providers, the out-of network benefit level
will apply. However, you will not be responsible for charges in excess of BCBS allowed
amounts. If you use “non-participating providers,” you will be responsible for charges in excess
of BCBS allowed amounts and it won’t apply to your deductible or out-of-pocket maximum.
46

Retiree Health Care SPD Effective January 1, 2012
There may be times when a specific type of in-network provider is not available in your area. If
you’re unable to locate an in-network provider, call the BCBS customer service department
regarding provider availability in your area. When necessary, a network exception will be
granted allowing you to receive the in-network level of benefits for services received from an
out-of-network provider. However, you will be responsible for notifying BCBS prior to receiving
certain services or being admitted to the hospital. See the section “Preadmission Notification and
Prior Authorization for BCBS-Administered Benefits,” in this SPD for more information. In
addition, you may need to file your own claim. See “Filing Health Care Claims – BCBS” in this
SPD for more information.
See the “Glossary of Terms” section in this SPD for definitions of in-network, out-of-network,
participating and non-participating providers.
Comprehensive Option
This option lets you and your covered dependents choose where you receive eligible medical
services, including second opinions. If you receive services from a BlueCard Traditional
provider, the Program pays a greater portion of the cost of covered services. The BlueCard
Traditional network also applies to covered dependents not residing with you (such as noncustodial
dependents or dependents attending school away from home).
When using a BlueCard Traditional provider, you will receive the “participating provider” level
of benefits. If you do not, you will receive the “non-participating” provider level of benefits. You
will also be responsible for charges in excess of BCBS allowed amounts which do not apply to
your deductible or out-of-pocket maximum. (See the definitions of participating and nonparticipating
providers in the “Glossary of Terms” section in this SPD.) BlueCard Traditional
providers are listed on the BCBS Web site* or are available by calling their customer service
department (see the “Important Resources” section in this SPD).
* Every effort is made to ensure that the list of providers on the BCBS Web site is up-to-date and accurate.
However, the network is subject to change throughout the year. It is your responsibility to verify that the provider
you or a covered family member uses is in the BlueCard Traditional network. You should call the BCBS customer
service department or access their Web site before you receive care to find out if a specific provider continues to be
part of the network.
You are responsible for notifying BCBS prior to receiving certain services or being admitted to
the hospital. (See the section “Preadmission Notification and Prior Authorization for BCBS-
Administered Benefits” in this SPD for more information.) If you use a non-participating
provider, you may need to file your own claim. See “Filing Health Care Claims – BCBS” in this
SPD for more information.
Blue Distinction Centers for Specialty Care ® – Select medical facilities that have been awarded
designation because they have demonstrated expertise in delivering quality healthcare, under
objective selection criteria. Except for transplants, Blue Distinction Centers are intended to treat
members age 18 and older. Although Blue Distinction Centers currently only exist for Bariatric
Surgery, Cardiac Care, Complex and Rare Cancers, Knee and Hip Replacements, Spine Surgery
and Transplants, additional centers may be added in the future. If new centers are added, they
can be found at http://www.bluecrossmn.com/usb.
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Retiree Health Care SPD Effective January 1, 2012
Allowed Amounts
To make sure the fees charged by providers are not excessive, BCBS pays based on “allowed
amounts.” The allowed amount is the negotiated amount of payment that a participating provider
has agreed to accept as payment in full (less deductibles, coinsurance and copayments) for a
covered service at the time a claim is processed. All Program payments are based on the allowed
amount. The allowed amount may vary from one provider to another for the same service. Also,
BCBS may periodically adjust the allowed amount.
If participating providers charge more than the allowed amount, the difference will appear in the
provider reduction column on your Explanation of Benefits (the statement sent from BCBS
following a claim). Except for certain locations and for non-covered services, you should not be
billed for any amounts exceeding allowed amounts when you use participating providers. Refer
to the “Which Network Providers to Use” section of this SPD for more information.. If you are
so billed, do not pay the invoice. Check with your health care provider or the BCBS customer
service department.
When you obtain health care services through the BlueCard Program outside the geographic area
BCBS of MN serves, the amount you pay for covered services is usually calculated on the lower
of:
1. The billed charges for your covered services; or
2. The negotiated price that the on-site Blue Cross and/or Blue Shield Plan (“Host Blue”) passes
on to the Claims Administrator.
Often, this “negotiated price” consists of a simple discount that reflects the actual price paid by
the Host Blue. Sometimes, however, the negotiated price is either 1) an estimated price that
factors expected settlements, withholds, any other contingent payment arrangements and nonclaims
transactions with your health care provider or with a specified group of providers into the
actual price; or 2) billed charges reduced to reflect an average expected savings with your health
care provider or with a specified group of providers. The price that reflects average savings may
result in greater variation (more or less) from the actual price paid than will the estimated price.
The negotiated price will be prospectively adjusted to correct for over- or underestimation of past
prices. The amount you pay, however, is considered a final price and will not be affected by the
prospective adjustment.
Statutes in a small number of states may require the Host Blue either 1) to use a basis for
calculating your liability for covered services that does not reflect the entire savings realized or
expected to be realized on a particular claim; or 2) to add a surcharge. If any state statutes
mandate liability calculation methods that differ from the usual BlueCard method noted above or
require a surcharge, the Claims Administrator will calculate your liability for any covered health
care services according to the applicable state statute in effect at the time you received your care.
Regardless of the plan you are enrolled in, if you obtain care from a non-participating
provider, you are responsible for paying the difference between the billed charge and the
allowed amount if your provider charges more than the allowed amount. The additional
cost would depend on what your physician charges. For expensive procedures, this amount
could be significant. Also, this excess amount will not apply to the deductible or out-ofpocket
maximum.
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Retiree Health Care SPD Effective January 1, 2012
For BCBS participants using a non-participating provider, if the provider is:
• a facility in Minnesota, the allowed amount is a designated percentage of the facility’s billed
charges. Outside of Minnesota, the allowed amount is determined by the local Blue Cross
and/or Blue Shield Plan, unless that amount is greater than the billed charge, or no allowed
amount is provided by the local Blue Plan. In that case, the allowed amount is determined
from a Medicare-based fee schedule. If such pricing is not available, payment will be based
on a percentage of the billed charges.
• a physician or clinic in Minnesota, the allowed amount is the lesser of: (1) the
Nonparticipating Provider Professional Services in Minnesota Fee Schedule or (2) a
designated percentage of the billed charges. Outside of Minnesota, the allowed amount is
determined by the local Blue Cross and/or Blue Shield Plan, unless that amount is greater
than the billed charge, or no allowed amount is provided by the local Blue Plan. In that case,
the allowed amount payment will be based on a percentage of pricing obtained from a
nationwide provider reimbursement database that considers various factors, including the zip
code of the place of service and the type of service provided. If this database pricing is not
available for the service provided, payment will be based on the lesser of: (1) the
Nonparticipating Provider Professional Services in Minnesota Fee Schedule or (2) a
designated percentage of the billed charges.
When you receive care from certain non-participating professionals, the reimbursement to the
non-participating professional may include some of the costs that you would otherwise be
required to pay (e.g., the difference between the allowed amount and the provider's billed charge)
as well as the services may be paid at the highest level of benefits. This applies in limited
circumstances when you receive care from non-participating professionals and you did not have
the opportunity to select the provider. Examples of this situation include diagnostic lab,
independent diagnostic X-ray and independent anesthesia providers.
To locate in-network/participating providers, call the BCBS customer service department or
access their Web site*. (See the “Important Resources” section in this SPD.) It is your
responsibility to confirm that the provider you use is an in-network/participating provider.
* Every effort is made to ensure that the list of providers on the BCBS Web site is up-to-date and accurate.
However, the network is subject to change throughout the year. It is your responsibility to verify that the provider
you or a covered family member uses is in the network associated with your health care option. You should call
BCBS’s customer service department or access their Web site before you receive care to find out if a specific
provider continues to be part of the network.
Example
The following example of a retiree enrolled in the Early Retiree Medical option, shows how
coverage is calculated when you use a non-participating or participating provider, assuming your
annual deductible has already been satisfied. In the example, the physician's charges exceed the
Program's allowed amount.
Non-Participating Participating
Billed charge for covered service: $100 Billed charge for covered service: $100
Allowed amount: $85 Allowed amount: $85
Non-participating coverage (plan pays 55% $46.75 Participating coverage (plan pays 75% $63.75
of $85):
of $85):
You pay $100 minus $46.75: $53.25 You pay $85 minus $63.75: $21.25
49

Retiree Health Care SPD Effective January 1, 2012
Transition of Care
If you or a covered family member is currently being treated by a provider who is not in the
network applicable to your location and health care option, and treatment is expected to continue
after you enroll in the Early Retiree Medical or Comprehensive option, you or your covered
family member may qualify for Transition of Care (TOC). TOC is only available for the
treatment of acute conditions and not for the convenience of the member being treated. Examples
of acute conditions are end-stage renal disease and dialysis, non-surgical cancer therapies
(including chemotherapy and radiation), transplants (solid organ and bone marrow), and
conditions where transition of care is required by federal law. Mental heath and substance abuse
treatment are reviewed on a case-by-case basis.
TOC allows you to be treated by your current provider for a specified period of time and receive
the higher level of benefits. The length of time depends on the individual's situation. To apply for
TOC, you and your physician will be required to complete a form and possibly submit
supporting medical information related to your request. Upon receipt of the information, BCBS
will review your request and notify you of its approval or denial.
If approved, the notification will tell you for how long the approval is in effect. During this time,
you are responsible for notifying BCBS of MN prior to receiving certain services or being
admitted to the hospital. (See the section “Preadmission Notification and Prior Authorization for
BCBS-Administered Benefits” in this SPD for more information.) In addition, you may need to
file your own claim. See “Filing Health Care Claims – BCBS” in this SPD for more information.
For additional information on TOC, call the BCBS of MN customer service department at the
number listed in the “Important Resources” section of this SPD, or access the BCBS of MN Web
site for forms.
If you or a covered family member is pregnant and expects to be in the second or third trimester
as of the effective date of coverage, you/she will automatically be eligible for TOC through the
first postpartum visit. But you or your family member must still contact BCBS of MN to request
the coverage.
Kaiser expects that all members who join their plan do so with the knowledge they will receive
care from their participating providers only.
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Retiree Health Care SPD Effective January 1, 2012
Preadmission Notification and Prior Authorization for BCBS of MN-
Administered Benefits
Preadmission Notification*
BCBS needs to be notified of planned (non-emergency) admissions before you or a covered
dependent is admitted. This process is known as “preadmission notification.” Verify with your
provider if this is a service they will perform for you or if you will need to complete the
preadmission notification. Ultimately, you are responsible for ensuring preadmission notification
has been made to BCBS.
Preadmission notification applies for the following facilities**
1. All hospital admissions;
2. Rehabilitation facility admissions;
3. Long-term acute care (LTAC) admissions;
4. Residential mental health and substance abuse treatment facilities; and
5. Outpatient mental health and substance abuse treatment facilities providing partial
hospitalization.
This list may not be exhaustive and is subject to change.
* Final payment of benefits is based on the coverage you have on the day services are received, whether lifetime
benefit maximums have been exceeded, and whether the service authorized is the service billed. Any decision to
undergo treatment rests with the patient, subscriber, and the provider. If you want to verify whether a service is
covered, you must call BCBS.
** If Medicare is the primary payer for you or a covered dependent, “preadmission notification” does not apply,
except for admissions for Transplants and Bariatric Surgery.
Preadmission Notification Process
In order to avoid liability for charges that are not considered medically necessary, notification is
recommended for admissions to a participating facility. However, notification is required for
admissions to a non-participating facility for the Comprehensive option or for admissions to an
out-of-network facility for the Early Retiree Medical option. If BCBS is not notified before you
or a covered dependent is admitted, any benefit payment payable under the plan is reduced. This
reduction is called a Non-Notification Penalty. A Non-Notification Penalty of $300 per
admission (or the amount of the covered expense, if less than $300), will apply. The Non-
Notification Penalty does not apply to your deductible or out-of-pocket limits. If notification is
not provided (whether recommended or required), and it’s determined at the point the claim is
processed that services were not medically necessary, you are liable for all of the charges.
To provide preadmission notification, call BCBS at least five working days before a planned
admission. The number to call is on the back of your BCBS ID card. After you call, a patient
care coordinator will determine if the admission is medically necessary and consult with your
admitting physician regarding your care. In addition to preadmission notification, you should
also obtain prior authorization for any services related to the admission for which prior
authorization is recommended. See “Prior Authorization” later in this section.
51

Retiree Health Care SPD Effective January 1, 2012
Emergency Admission Notification
In order to avoid liability for charges that are not considered medically necessary, notification is
recommended for unplanned admissions as a result of a medical emergency or injury as soon as
reasonably possible or within 48 hours of the admission. For childbirth, notification is necessary
if your stay will extend beyond 48 hours after a vaginal delivery or 96 hours after a Cesarean
delivery (see the section “Inpatient Maternity Care” in this SPD). As mentioned previously under
“Preadmission Notification”, verify with your provider if this is a service they will perform for
you or if you will need to complete the notification. Ultimately, you are responsible for ensuring
notification has been made to BCBS. See “Preadmission Notification Process” earlier in this
section for information about how to provide notification to BCBS. If notification is not provided
(whether recommended or required), and it’s determined at the point the claim is processed that
services were not medically necessary, you are liable for all of the charges.
Appealing a Preadmission Notification Decision
If you disagree with a BCBS’ preadmission notification determination, you can seek additional
review of that claim by following the procedure described under “Request for Review of
Adverse Benefit Determinations” in the “Internal ERISA Claims Procedures” section in this
SPD.
Prior Authorization*
Prior to receiving certain services, it is recommended that you contact BCBS for prior
authorization to make sure the services are medically necessary before you or a covered
dependent receives them. Verify with your provider if this is a service they will perform for you
or if you will need to complete the prior authorization request. When you request prior
authorization, BCBS will determine whether the services are medically necessary, appropriate,
and eligible under the terms of your contract. If the services are determined to be cosmetic or
otherwise not medically necessary, the services would not be covered and will be your
responsibility. The services for which a prior authorization is recommended are:
• Cosmetic versus medically necessary procedures - including, but not limited to:
brow ptosis repair; excision of redundant skin (including panniculectomy); reduction
mammoplasty; rhinoplasty; scar excision/revision; otoplasty; mastopexy
• Coverage of routine care related to cancer clinical trials
• Dental and oral surgery including, but not limited to:
services that are accident-related for the treatment of injury to sound and healthy natural
teeth; temporomandibular joint (TMJ) surgical procedures; and orthognathic surgery
• Drugs - including, but not limited to:
growth hormones; intravenous immunoglobulin (IVIG); oral fentanyl; subcutaneous
immunoglobulin; rituximab for off-label usage; NPlate; Promacta; Tysabri; Cinryze;
intravitrel implants; insulin-like growth factors; chelation therapy; botulinum toxin injections
for off-label usage
• Durable Medical Equipment (DME), prosthetics and supplies including, but not limited to:
unlisted DME codes over $1,000; functional neuromuscular electrical stimulation; manual
and motorized wheelchairs and scooters; respiratory oscillatory devices; heavy duty and
enclosed hospital beds; pressure reducing support surfaces (group 2 and 3); wound healing
treatment; implantable hearing devices or prosthetics; continuous glucose monitors; amino
acid-based elemental formula; bone growth stimulators; communication assist devices;
microprocessor controlled prosthetics
52

Retiree Health Care SPD Effective January 1, 2012
• Genetic testing including, but not limited to hereditary breast cancer and/or ovarian
cancer
• Home health care
• Home infusion care involving drugs for which prior authorization is required
• Hospice care
• Humanitarian use devices (defined as devices that are intended to benefit patients by
treating or diagnosing disease or condition that affects fewer than 4,000 individuals in the
United States per year, classified under the FDA Humanitarian Device Exemption)
• Imaging services including, but not limited to:
Breast Magnetic Resonance Imaging (MRI); CT colonography (virtual colonoscopy)
• Infertility treatment
• Physical and occupational therapy (visits beyond the Programs’s annual 50 visit combined
maximum)
• Speech therapy (visits beyond the Program’s annual 25 visit maximum)
• Surgical procedures including, but not limited to:
bariatric surgery; hyperhidrosis surgery; spinal cord stimulators; subtalar arthroereisis for
treatment of foot disorders; surgical treatment of obstructive sleep apnea and upper airway
resistance syndrome; vagus nerve stimulation (for all conditions); spinal fusion; pelvic floor
stimulation; ventricular assist devices
• Transplants, except kidney and cornea
This list may not be exhaustive and BCBS reserves the rights to revise, update, and/or add to this
list at anytime without notice. The current list is available by calling BCBS Customer Service.
* Final payment of benefits is based on the coverage you have on the day services are received, whether lifetime
benefit maximums have been exceeded, and whether the service authorized is the service billed. Any decision to
undergo treatment rests with the patient, subscriber, and the provider. If you want to verify whether a service is
covered, you must call BCBS.
Prior Authorization Request Process
In order to avoid liability for charges that are not considered medically necessary, a prior
authorization is required. While a Non-Notification Penalty will not apply if you fail to do so,
should you not request prior authorization, and it’s determined at the point the claim is processed
that services were not medically necessary, you are liable for all of the charges.
Prior authorization requests should be submitted to BCBS at least 10 working days before the
service is performed. You may submit your request by phone; the number to call is on the back
of your BCBS ID card.
If additional visits for occupational, physical and speech therapy will be needed beyond the
Program’s annual visit maximum, you need to contact BCBS prior to the 51 st visit for
occupational or physical therapy and prior to the 26 th visit for speech therapy. If the services are
considered medically necessary, additional visits will be covered until either the condition
resolves or the end of the plan year – whichever comes first. If the services are determined to not
be medically necessary, the services would not be covered once the Program’s annual visit
maximum has been reached and would be your responsibility.
53

Retiree Health Care SPD Effective January 1, 2012
Appealing a Prior Authorization Decision
If you disagree with BCBS’ prior authorization determination, you can seek additional review of
that claim by following the procedure described under “Request for Review of Adverse Benefit
Determinations” in the “Internal ERISA Claims Procedures” section in this SPD.
When You Have Other Coverage – BCBS of MN
If you or your dependents are covered by the Early Retiree Medical or Comprehensive option
and by another employer’s health plan, the U.S. Bank option will integrate its payments for
medical related services with those of the other group plan. For information related to pharmacy,
see the “When You Have Other Coverage – Medco” section in this SPD. The U.S. Bank options
do not integrate payments with non-group health plans or individual polices issued in most
states.*
* Pursuant to law, some states are required to integrate with non-group or individual health plans. In these instances,
normal rules (as explained above) are followed for determining which plan is primary.
Integration means that benefits from both plans are coordinated. You and your dependents will
not, in most cases, receive 100% reimbursement for health care expenses when you have
coverage in two group plans. If certain benefit plans are structured identically, the secondary
plan might not pay any benefits. As a result, it may not be economically advantageous to be
covered by two group plans.
In order for integration to occur, one of the plans is determined to be primary and the other,
secondary. The primary plan pays first and the secondary plan pays second.
The following rules apply to determine which plan is primary:
• Plans providing benefits or services under workers’ compensation, personal injury protection
(PIP) or no-fault insurance are always considered primary.
• Dependents of pre-65 non-Medicare eligible retirees eligible for Medicare solely on the basis
of having end-stage renal disease (first 30 months only), the benefit option is primary.
• A plan that covers a person as an employee or a dependent of an employee is primary over a
plan that covers a person under COBRA or other continuation coverage required by statute.
• A retiree’s health plan is considered primary for the retiree unless the retiree is also covered
by an active employee plan. A plan that covers the retiree as a dependent (unless it is an
active employee plan) is secondary.
• If a retiree or dependent is covered by an active employee plan, the active plan is considered
primary for that individual.
• For dependent children covered by the plans of both parents, the “birthday rule” applies,
which means the plan of the parent whose birthday falls earlier in the year pays first.
• Dependents of pre-65 non-Medicare eligible retirees eligible for Medicare due to disability
and who are not working, Medicare Parts A and B are primary.
• For children of legally separated or divorced parents, the plan of the parent who has child
custody pays first (unless the divorce decree indicates otherwise).
• If you remarry or enter into a domestic partnership and you have custody, your plan is
primary - followed by your new spouse’s/domestic partner’s plan and then your former
spouse’s/domestic partner’s plan.
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Retiree Health Care SPD Effective January 1, 2012
How Integration Works
When your U.S. Bank Retiree Health Care Program is the secondary plan, the medical bill must
first be submitted to the other group plan (the primary plan) for payment. The bill should then be
sent, along with the “Explanation of Benefits” from the primary plan, to BCBS of MN at the
following address:
BCBS of Minnesota
3535 Blue Cross Road
P.O. Box 64560
St. Paul, MN 55164
The amount the Program pays equals what the Program would have paid if it were primary
MINUS what the primary plan paid. Refer to the following examples:
Examples of Integration
Early Retiree Medical Option Early Retiree Medical Option
Family coverage (In-Network) Family coverage (In-Network)
Total charge $5,000 $5,000
What U.S. Bank would pay if it $1,500 ($5,000 minus 3000 $1500 ($5,000 minus $3000
were primary plan
deductible = $2000 X
deductible = $2000 X
75%)
75%)
What primary plan pays $2,700 $1,200
What U.S. Bank Health Care $0 Difference between what $300 Difference between
Program pays
primary plan pays and
what primary plan pays
what U.S. Bank Program and what U.S. Bank
would have paid if it were Program would have
primary
paid if it were primary
What YOU pay $2,300 ($5,000 - $2,700) $3500 ($5,000 - $1,200 - $300)
In determining how to integrate benefits, BCBS will need to receive and release medical (and
possibly other) information. Except as otherwise required by applicable law BCBS does not need
to tell you or get your consent to exchange needed information with other organizations to apply
the integration-of-benefit rules.
Liability of Another Party: When Another Person is Responsible for Your
Covered Health Care Expenses
As a condition of receiving benefits under the U.S. Bank Retiree Health Care Program, you agree
to assign and subrogate any and all of your rights of recovery from any other liable party. This
means that if you or a covered dependent becomes ill or is injured by another party, and the
U.S. Bank Retiree Health Care Program pays expenses for which another party is liable, you are
required to reimburse the Program from what you receive from the legally responsible party or
from any settlement or judgment. You also agree not to do anything to interfere with the plan’s
right to recovery. Failure to comply with these requirements will result in loss of benefits. You
may be required to sign an agreement to this effect. (There are other important requirements
concerning the Program’s reimbursement and subrogation rights. See the “Benefits
Administrative Information” section in this SPD.)
55

Retiree Health Care SPD Effective January 1, 2012
What Happens When You or a Dependent Turn Age 65 or Become Medicare
Eligible Before Age 65
If you or a dependent turn age 65 or become Medicare Eligible before age 65 you need to refer to
the “MEDICARE ELIGIBLE RETIREES AND DEPENDENTS TURNING AGE 65” section in
this SPD and also the “HOW COVERAGE WORKS IF YOU ARE AGE 65 OR OLDER OR
PRE-65 AND MEDICARE ELIGIBLE” section in this SPD.
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Retiree Health Care SPD Effective January 1, 2012
MEDICARE ELIGIBLE RETIREES AND
DEPENDENTS TURNING AGE 65
Note: If you are enrolled in Kaiser Colorado, this information does not apply to you. Please see
the separate Kaiser materials.
What Happens When You Turn Age 65 or Become Medicare Eligible before
Age 65
In order to continue coverage under the Program when you turn 65 or become Medicare eligible
before age 65, you must enroll yourself and any Medicare eligible dependents in the
UnitedHealthcare or Medica Plan option available to you in your area. You will receive
information regarding enrollment in the UnitedHealthcare or Medica Plan option approximately
90 days prior to your 65 th birthday. Your enrollment form(s) (for you and any eligible
dependents) must be received by the U.S. Bank Employee Service Center and processed, by the
deadline on your enrollment materials or you will no longer be enrolled in the Program. The
effective date of coverage into the UnitedHealthcare or Medica Plan option will be the first of the
month in which you turn age 65 (as long as your UHC/Medica application has been processed).
If your birthday is on the first day of the month, then your coverage under the UnitedHealthcare
or Medica Plan option will be effective on the first of the prior month (as long as your
UHC/Medica application has been processed). If you become Medicare eligible before age 65,
you must call the U.S. Bank Employee Service Center at 1-800-806-7009 and request enrollment
materials for the UnitedHealthcare or Medica Plan option.
If you have non-Medicare eligible dependents under age 65, your dependent will remain in their
current Program option.
In order to enroll in the UnitedHealthcare or Medica Plan option, you and your Medicare eligible
dependents, must be enrolled in Medicare Parts A and B to receive benefits. If you or your
dependents do not enroll in Medicare Parts A and B, you or your dependents will not be eligible
to continue coverage in the Program.
You will receive a new ID card. You will need to show your new ID card, plus your Medicare
card, to your health care providers when receiving services.
What Happens When a Dependent Turns Age 65 or becomes Medicare
Eligible Before Age 65
If you are already enrolled in the UnitedHealthcare or Medica Plan option, your covered
dependent must enroll in the UnitedHealthcare or Medica Plan option at the time they turn age
65 or when they become Medicare eligible before age 65. Enrollment information will be
provided to your covered dependent 90 days prior to turning age 65. Your dependent must enroll
by the deadline on the enrollment materials or your dependent will no longer be enrolled in the
Program. The effective date of coverage into the UnitedHealthcare or Medica Plan option will be
the first of the month in which your dependent turns age 65 (as long as your UHC/Medica
application has been processed). If your dependent’s birthday is on the first day of the month,
then their coverage under the UnitedHealthcare or Medica Plan option will be effective on the
first of the prior month (as long as your UHC/Medica application has been processed).
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Retiree Health Care SPD Effective January 1, 2012
In order to enroll in the UnitedHealthcare or Medica Plan option, your dependent must be
enrolled in Medicare Parts A and B to receive benefits. If your dependent is not enrolled in
Medicare Parts A and B, they will not be eligible to continue coverage in the Program.
If you and your covered dependents are enrolled in the Early Retiree Medical or Comprehensive
option, and your dependent turns age 65 or becomes Medicare eligible before age 65, you and
your dependents will remain in the Early Retiree Medical or Comprehensive option. Your
coverage cost also will not change when a covered dependent turns age 65 or becomes Medicare
eligible before age 65. However, for that dependent, Medicare Parts A and B will be considered
the primary insurer, effective the first of the month in which the dependent turns age 65 (or the
first of the prior month if the dependent’s birthday is on the first of the month). The Program will
assume that your dependent has enrolled in Medicare Parts A and B and Blue Cross and Blue
Shield of Minnesota will process your claims as if you had Medicare Part A and Part B, whether
or not that is actually the case. If your dependent doesn’t have Medicare Part A and Part B, your
dependent must pay the portion that Medicare would have paid. The Program only pays benefits
when the benefit amount payable under the Program exceeds the Medicare payment.
Preadmission Notification and Prior Authorization
If your covered dependent is age 65 or older and enrolled in the Early Retiree Medical option or
the Comprehensive option, certain requirements, such as “preadmission notification” and “prior
authorization” do not apply, because Medicare is primary except for certain organ transplant
services and bariatric surgery. See the Transplants section or the Bariatric Surgery section in this
SPD.
Your Benefit Option Integration With Medicare
Currently, the Medicare Program consists of Part A for inpatient services, and Part B for
physician services, outpatient services, and supplies and equipment. If your covered dependent is
enrolled in the Early Retiree Medical option or the Comprehensive option and is eligible for
Medicare, the Program assumes that your dependent is enrolled in Medicare Parts A and B,
whether or not that is actually the case. For Parts A and B, Medicare is considered their primary
insurer. Because the U.S. Bank Retiree Health Care Program (the Program) integrates
coverage with Medicare Part A and Part B, your dependents must be enrolled in both
programs to receive your full benefits. (For example: If you don’t enroll in Medicare Part B,
BCBS will process your claims as if you had Medicare Part B. You must pay the portion of the
claim that Medicare would have paid under Part B.) The Early Retiree Medical and
Comprehensive options work in conjunction with Medicare Parts A and B, and pays benefits
when the benefit amount payable under the Program (the amount that the option would pay if it
were your primary insurer) exceeds the Medicare payment.
Here is how Medicare Parts A and B and the Early Retiree Medical and Comprehensive options
work together:
1. Medicare pays its benefit after you satisfy the applicable Medicare deductible(s).
2. The Program calculates its normal benefit based on Medicare’s approved amount. If the
Program’s normal benefit (after your plan deductible) is greater than the Medicare payment,
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Retiree Health Care SPD Effective January 1, 2012
the Program pays the difference between the Medicare payment and the Program’s normal
benefit.
3. You pay the remaining amount.
When Medicare provides the same level of benefits for a service as the Program would pay (if it
were primary), the Program does not pay any benefit for that service. This means that the
Program may not pay any benefit for many medical services. If Medicare pays less than the
Program, the Program will pay the difference. If there is no Medicare coverage for a service
covered by the Program, the Program pays the benefit for that service.
Example of Integration With Medicare (enrolled in Early Retiree Medical option-Family
coverage level)*
Total Charge $1,300
Medicare approved amount $1,000 This is just an example. Actual Medicare approved
amounts are based on Medicare fee schedules.
What the Program would have $0 75% after $3000 combined medical/pharmacy
paid if primary
deductible (based on Medicare’s approved amount).
What Medicare pays $720 80% of approved amount after $100 deductible.
What the Program pays $0 Difference between what Medicare pays and what the
Program would pay if it were primary.
What you pay* $280* ($1,000-$720=$280)*
*The example provided assumes the provider has accepted assignment with Medicare. If the provider does not
accept assignment with Medicare, you may be billed up to the total charge. Also, the example assumes you have
enrolled in Medicare Parts A and B if you are eligible to do so. If that was not the case, you would also be
responsible for the amount noted in the row “What Medicare Pays” ($720).
Claiming Health Care Benefits with Medicare
If your dependent is enrolled in the Early Retiree Medical or Comprehensive option, some
providers will file claims with Medicare and then BCBS. If your dependent’s provider does not,
your dependent will need to file their claims with Medicare first. When Medicare has processed
their claim, they will receive an Explanation of Benefits. Send this form, along with the claim
form from BCBS, to the address on the back of the ID card. Your dependent will need to contact
BCBS for claim forms.
To be eligible for payment, your dependent’s claims must be received by BCBS within 12
months from the date of service.
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Retiree Health Care SPD Effective January 1, 2012
HOW COVERAGE WORKS IF YOU ARE AGE 65
OR OLDER OR PRE-65 AND MEDICARE
ELIGIBLE
Note: If you are enrolled in Kaiser Colorado, this information does not apply to you. Please see
the separate Kaiser materials.
Your Benefit Option If You are Medicare Eligible
If you are age 65 and older or pre-65 and Medicare eligible. You can enroll in the insured
UnitedHealthcare or Medica Plan option available in your area up to 90 days prior to your
termination date. You can initiate the enrollment process online at
www.yourbenefitsresources.com/usbank or by calling the U.S. Bank Employee Service Center.
Once you initiate your enrollment, you will be sent an enrollment kit, which will include an
enrollment form. You must be enrolled in Medicare Parts A and B in order to enroll in the
Program. If you are not enrolled in Medicare Parts A and B, your application for enrollment will
not be accepted. Once the U.S. Bank Employee Service Center receives your completed and
signed enrollment application, this information is submitted to CMS (Medicare) for verification
of eligibility. If CMS rejects your enrollment application, the U.S. Bank Employee Service
Center will contact you for additional information in order to resubmit your application. The
effective date of coverage will be the first of the month following the date when your application
is received and processed or the date you are first eligible to enroll in the Program, whichever is
later. You should refer to the UnitedHealthcare or Medica Plan option materials.
If you and your eligible dependents are age 65 and older or pre-65 and Medicare eligible.
You and your dependent(s) can enroll in the insured UnitedHealthcare or Medica plan option
available in your area up to 90 days prior to your termination date. You can initiate the
enrollment process online at www.yourbenefitsresources.com/usbank or by calling the U.S. Bank
Employee Service Center. Once you initiate your enrollment, you will be sent an enrollment kit,
which will include enrollment forms. You and your dependent(s) must be enrolled in Medicare
Parts A and B in order to enroll in the Program. If you and your dependent(s) are not enrolled in
Medicare Parts A and B, your application for enrollment will not be accepted. Once the U.S.
Bank Employee Service Center receives your completed and signed enrollment applications (a
separate application needs to be completed by you and each of your Medicare eligible
dependents), this information is submitted to CMS for verification of eligibility. If CMS rejects
your enrollment application(s), the U.S. Bank Employee Service Center will contact you for
additional information in order to resubmit your application. The effective date of coverage will
be the first of the month following the date when your application(s) is received and processed or
the date you are first eligible to enroll in the Program, whichever is later. You should refer to the
UnitedHealthcare or Medica Plan option materials.
If you are age 65 and older or pre-65 and Medicare eligible and have dependents that are
pre-65 and not Medicare eligible. You can enroll in the insured UnitedHealthcare or Medica
Plan option available in your area and your dependent can enroll in the pre-65 option available in
your area, until they turn age 65 or become Medicare eligible prior to age 65 (see the “How
Coverage Works if You are Under Age 65 And Not Medicare Eligible” section in this SPD).
You can enroll yourself and your dependent(s) in the Program up to 90 days prior to your
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Retiree Health Care SPD Effective January 1, 2012
termination date. You can initiate the enrollment process online at
www.yourbenefitsresources.com/usbank or by calling the U.S. Bank Employee Service Center.
Once you initiate your enrollment you will be sent an enrollment kit, which will include an
enrollment form. You must be enrolled in Medicare Parts A and B in order to enroll in the
Program. If you are not enrolled in Medicare Parts A and B, your application for enrollment will
not be accepted. Once the U.S. Bank Employee Service Center receives your completed and
signed enrollment application, this information is submitted to CMS for verification of
eligibility. If CMS rejects your enrollment application, the U.S. Bank Employee Service Center
will contact you for additional information in order to resubmit your application. The effective
date of coverage in the insured UnitedHealthcare or Medica Plan option will be the first of the
month following the date when your application is received and processed or the date you are
first eligible to enroll in the Program, whichever is later. The effective date of coverage for your
dependent(s) enrolling in one of the pre-65 options, will be the same date as your coverage is
effective, if you enroll them by the enrollment deadline.
Your Prescription Drug Coverage under the Program and Medicare Part D
Beginning January 1, 2006, Medicare Part D prescription drug coverage became available. This
coverage is available if you enroll in Medicare Part D and pay an additional Part D premium.
However, the U.S. Bank option will continue to provide primary prescription drug coverage at
NO ADDITIONAL cost, except for prescriptions covered under Medicare Parts A and B. In
fact, the prescription drug coverage under the Program provides more cost effective coverage
than what is offered under standard Medicare Part D. Because prescription coverage is already
available under the Program, we strongly recommend that you DO NOT ENROLL IN
MEDICARE PART D.
If you are enrolled in the Medica or Comprehensive option and you enroll in Medicare Part D
coverage, you will no longer receive prescription drug coverage under the U.S. Bank option, and
your monthly U.S. Bank option premium will not be reduced. Your monthly premium covers
both medical and pharmacy benefits, and it will not be changed. If you decide to enroll in
Medicare Part D, you will end up paying additional unnecessary premiums, as you will be
paying a premium for both Medicare Part D and the U.S. Bank option.
If you are enrolled in the Medica or Comprehensive option and you enroll in Medicare Part D
prescription drug coverage, and later decide to drop your Medicare Part D coverage, you will be
eligible to reenroll for U.S. Bank prescription drug coverage, as long as you are actively enrolled
in a U.S. Bank Retiree Health Care Program option (except for the Kaiser health care option).
Your U.S. Bank prescription drug coverage will be effective on the first of the month following
the date that your Medicare Part D prescription drug coverage is dropped and you contact the
U.S. Bank Employee Service Center, unless you contact the service center on the first of the
month. In this case, your coverage will become effective on that day.
If your coverage option is the UHC plan and you enroll in a Medicare Part D prescription drug
plan, Medicare will automatically terminate your UHC coverage and you will no longer be
enrolled in the U.S. Bank Retiree Health Care Program. In addition, your dependent’s coverage
will be terminated, as dependents are not eligible to be enrolled in the Program if the retiree is
not enrolled.
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Retiree Health Care SPD Effective January 1, 2012
If your dependent’s coverage option is the UHC plan and (s)he enrolls in a Medicare Part D
prescription drug plan, Medicare will automatically terminate your dependent’s UHC coverage
and (s)he will no longer be enrolled in the U.S. Bank Retiree Health Care Program.
Vaccines: If you are enrolled in UnitedHealthcare or Medica, vaccines that are covered by
Medicare Part D are not covered by these medical carriers. However, these vaccines (such as the
vaccine for Shingles), will be covered by Medco if the prescription is filled at a participating
network retail pharmacy.
You should inform your physician that the vaccine is not covered by your medical carrier
(UnitedHealthcare or Medica). You will need to coordinate with both your physician and the
pharmacist at the retail pharmacy to ensure that the pharmacy stocks the particular vaccine, and
has someone onsite that can administer the medication. (See the “Vaccines Covered By Medicare
Part D” section in this SPD).
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Retiree Health Care SPD Effective January 1, 2012
PHARMACY
Note: If you are enrolled in Kaiser Colorado, this information does not apply to you. Please see
the separate Kaiser materials.
Medco Health Solutions (Medco) is the Claims Administrator for the pharmacy benefits included
in the Early Retiree Medical, Comprehensive, Medica and UnitedHealthcare options. The
information stated throughout the entire “Pharmacy” section relates to all of these options (unless
otherwise noted).
Refer to the section “How Coverage Works If You Are Age 65 Or Older Or Pre-65 And
Medicare Eligible” in this SPD for information about Medicare Part D prescription drug
coverage.
You need to be sure to show your Medco ID card when receiving prescriptions and Medco will
track your claims for you. Once your combined pharmacy/medical deductible for the Early
Retiree Medical option or the pharmacy deductible for the Comprehensive, UnitedHealthcare
and Medica options has been satisfied you will only be charged the applicable copayment or
coinsurance for eligible prescriptions, until you reach your combined pharmacy/medical out-ofpocket
maximum for the Early Retiree Medical option and the pharmacy out-of-pocket
maximum for the Comprehensive, UnitedHealthcare and Medica options.
Coverage includes two prescription drug-dispensing methods:
• Mail order using the Medco Pharmacy or Accredo (a division of the Medco Pharmacy
for specialty drugs); and
• Retail Pharmacy.
Pharmacy Deductibles, Coinsurance and Maximums
Note: This section only applies to you if you are enrolled in the Comprehensive, Medica or
UnitedHealthcare options. If you are enrolled in the Early Retiree Medical option see the
“Deductibles, Coinsurance and Maximums” section in this SPD, for information on the
combined medical/pharmacy deductibles, coinsurance and maximums.
Deductible
A deductible is the per plan year amount you must pay toward eligible expenses before you and
the health care option begin to share covered expenses. The deductible is applied to the out-ofpocket
maximum. The deductible for the Comprehensive, UnitedHealthcare and Medica options
is an embedded deductible. Under the health care and pharmacy care options, there are two
different types of deductibles. They are: pharmacy and medical deductible. For a definition of
each of these deductibles, refer to the “Glossary of Terms” section in this SPD.
Deductibles are designed as per person and per family (i.e., the Retail Pharmacy deductible is
$250 per person or $750 per family). Family deductibles apply to a participant with two or more
covered dependents. If you have selected Family coverage but have only one covered dependent,
you and the dependent will each be responsible for the per person deductible.
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Retiree Health Care SPD Effective January 1, 2012
The following charges do not apply to your pharmacy deductible:
• Your monthly retiree health care premiums.
• Any costs not covered by your option.
• Any amounts that exceed the Program's allowed amounts when a non-participating Retail
Pharmacy is used. This also applies if you use a participating Retail Pharmacy, but do not
show your Medco ID card or for compound prescriptions not submitted directly to Medco by
the pharmacy.
• Any cost difference between a brand-name drug and a generic equivalent when a brand-name
drug is prescribed and a generic drug is available.
• Amounts paid toward the medical deductible.
• Coinsurance paid for medical services.
• Coinsurance and copayments for prescriptions purchased through the Medco Pharmacy or
Accredo.
• Specialty drugs not filled by Accredo when required.
• Any maintenance medications not filled by the Medco Pharmacy after the first two fills when
required.
• Charges that are not eligible to be applied to the combined medical deductible are also not
eligible to be applied to the pharmacy deductible. See the “Deductibles, Coinsurance and
Maximums” section in this SPD for the list.
Out-of-Pocket Maximum (Pharmacy)
The out-of-pocket maximum is the per plan year limit you must pay toward eligible expenses
before any additional eligible services you incur are paid by the health care option at 100% of the
allowed amount for the remainder of the year (as long as any applicable annual or lifetime
maximums have not been exceeded). The limit you pay includes the total of the applicable
deductible, copayments and coinsurance. There are two different types of out-of-pocket
maximums. They are: pharmacy and medical out-of-pocket maximum. For a definition of each
of these out-of-pocket maximums, refer to the “Glossary of Terms” section in this SPD. The
charges that do not apply to your deductible (listed previously) also do not apply to your out-ofpocket
maximum.
The family out-of-pocket maximum applies to participants with two or more covered
dependents. If you have selected Family coverage but have only one covered dependent, you and
the dependent will each need to meet the per person out-of-pocket maximum.
Copayments and Coinsurance
Copayments are payments you make on a per service basis for eligible services (after deductible
for retail pharmacy). The cost is the lesser of the allowed amount and the provider’s actual billed
charge. How much coinsurance you pay (after your applicable deductible and/or copayment is
met) depends on the service received and if you use a participating provider. The coinsurance
you pay is applied to the out-of-pocket maximum. If you receive services from a nonparticipating
provider, you will also be responsible for paying any amount in excess of the
allowed amount in addition to coinsurance. The excess amount you pay will not be applied to the
out-of-pocket maximum. A change to the cost during a plan year will not result in a recalculation
of any coinsurance paid. Coinsurance can be found in the “Pharmacy Coverage Summary”
section in this SPD. Copayments for prescriptions purchased through the Medco Pharmacy
(Medco’s mail order service) or Accredo (a division of the Medco Pharmacy for specialty drugs)
are not applied to any deductibles.
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Retiree Health Care SPD Effective January 1, 2012
Coinsurance is a percentage of the cost of the service that you pay for eligible expenses (after
deductible for Retail Pharmacy). The cost is the lesser of the allowed amount and the provider’s
actual billed charge. How much coinsurance you pay (after your applicable deductible and/or
copayment is met) depends on the service received and if you use a participating provider. The
coinsurance you pay is applied to the out-of-pocket maximum. If you receive services from a
non-participating provider, you will also be responsible for paying any amount in excess of the
allowed amount in addition to coinsurance. The excess amount you pay will not be applied to the
out-of-pocket maximum. A change to the cost during a plan year will not result in a recalculation
of any coinsurance paid. Coinsurance can be found in the “Health Care Option Summary”
section in this SPD. Coinsurance related to pharmacy coverage can be found in the “Pharmacy
Coverage Summary” section in this SPD.
The copayment/coinsurance you pay after the deductible (if applicable) depends on the type of
medication you receive and where you obtain the medication. In addition, if a brand-name
medication is dispensed when a generic is available – whether requested by you or your doctor –
you will pay the cost difference between the brand-name and generic medications, plus your
brand-name coinsurance. See the “Pharmacy Coverage Summary” section in this SPD for more
information on the copayment/coinsurance applicable for each option.
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Retiree Health Care SPD Effective January 1, 2012
Pharmacy Coverage Summary
Early Retiree Medical Option
Combined Pharmacy/Medical
Deductible (non-embedded) per
plan year
Combined Pharmacy/Medical
Out-of-Pocket Maximum (nonembedded)
per plan year
Formulary (Preferred) Drug List
Used
Mail Order Maintenance Drug
Provision Applies
• You pay $2,000 per person (only applies if Individual coverage level
elected)
• You pay $3,000 per Family
• You pay $5,000 per person (only applies if Individual coverage level
elected)
• You pay $7,500 per Family
Yes - See the “Formulary Drugs” section in this SPD for more information.
Yes - See the “Mail Order Maintenance Drug Provision” section in this SPD for
more information.
Diabetic Supply Exception Applies Yes – See the “Diabetic Supply Exception” section in this SPD for more
information.
Specialty Drug Provision Applies Yes - See the “Specialty Drug Provision” section in this SPD for more information.
Mail Order Using the Medco Pharmacy (up to a 90-day supply*) or Accredo (for specialty drugs per each 30-day
supply*)
Preferred Drugs Non-Preferred Drugs
If a generic drug is requested ... You pay $25 copayment per covered prescription.
If a brand-name drug is dispensed
and a generic drug IS available ...
If a brand-name drug is dispensed
and a generic drug IS NOT available
...
You pay 30% coinsurance ($50
minimum, $175 maximum) plus the cost
difference between the brand-name and
generic per covered prescription.
You pay 30% coinsurance ($50
minimum, $175 maximum) per covered
prescription.
You pay 45% coinsurance ($125
minimum, $250 maximum) plus the
cost difference between the brand-name
and generic per covered prescription.
You pay 45% coinsurance ($125
minimum, $250 maximum) per covered
prescription.
Retail Pharmacy (up to a 31-day supply*)
Preferred Drugs Non-Preferred Drugs
If a generic drug is requested at a You pay 20% coinsurance ($10 minimum**, $35 maximum) per covered
participating Retail Pharmacy ... prescription.
If a brand-name drug is dispensed at You pay 30% coinsurance ($20
You pay 45% coinsurance ($50
a participating Retail Pharmacy and minimum**, $175 maximum) plus the minimum**, $250 maximum) plus the
a generic drug IS available ... cost difference between the brand-name
and generic per covered prescription.
cost difference between the brand-name
and generic per covered prescription.
If a brand-name drug is dispensed at You pay 30% coinsurance ($20
You pay 45% coinsurance ($50
a participating Retail Pharmacy and minimum**, $175 maximum) per minimum**, $250 maximum) per covered
a generic drug IS NOT available ... covered prescription.
prescription.
When you use a non-participating You pay 50% coinsurance ($50 minimum**, no maximum) of the allowed amount
Retail Pharmacy ...
per covered prescription. If a brand-name drug is dispensed and a generic drug is
available, you will also pay the cost difference between the brand-name and generic
per covered prescription.
Where applicable, taxes will be added to copayment/coinsurance amounts. In addition, all copayment/coinsurance amounts
are paid after the deductible has been satisfied.
* Additional criteria as noted throughout the “Pharmacy” section in this SPD may apply to determine whether specific
drugs are covered and in what dosage or quantity amount. Please call Medco if you have questions about coverage
and/or limitations on the quantity or dosage amount covered for a specific prescription drug.
** Or the full cost if less than the minimum.
See the section “Glossary of Terms” in this SPD for all definitions and the “Deductibles,
Coinsurance and Maximums” section in this SPD for more information. In addition, refer to the
“What the Options Cover” section in this SPD for information related to covered medical services
under this Program.
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Retiree Health Care SPD Effective January 1, 2012
Pharmacy Coverage Summary, continued
Comprehensive, Medica and UnitedHealthcare Options
Retail Pharmacy Deductible
(embedded) per plan year (does not
apply to mail order using the Medco
Pharmacy)
Pharmacy Out-of-Pocket Maximum
(embedded) per plan year (there is no
out-of-pocket maximum for nonparticipating
or out-of-network)
Formulary (Preferred) Drug List
Used
• You pay $250 per person
• You pay $750 per family
• You pay $2,750 per person
• You pay $8,250 per family
Yes - See the “Formulary Drugs” section in this SPD for more information.
Diabetic Supply Exception Applies Yes – See the “Diabetic Supply Exception” section in this SPD for more
information.
Mail Order Maintenance Drug Yes - See the “Mail Order Maintenance Drug Provision” section in this SPD for
Provision Applies
more information.
Specialty Drug Provision Applies Yes - See the “Specialty Drug Provision” section in this SPD for more information.
Mail Order Using the Medco Pharmacy (up to a 90-day supply*) or Accredo (for specialty drugs per each 30-day supply*)
Preferred Drugs Non-Preferred Drugs
If a generic drug is requested ... You pay $25 copayment per covered prescription.
If a brand-name drug is dispensed and a
generic drug IS available ...
If a brand-name drug is dispensed and a
generic drug IS NOT available...
You pay 30% coinsurance ($60
minimum, $150 maximum) plus the cost
difference between the brand-name and
generic per covered prescription.
You pay 30% coinsurance ($60
minimum, $150 maximum) per covered
prescription.
You pay 45% coinsurance ($125
minimum, $250 maximum) plus the cost
difference between the brand-name and
generic per covered prescription.
You pay 45% coinsurance ($125
minimum, $250 maximum) per
covered prescription.
Retail Pharmacy (up to a 31-day supply*)
Preferred Drugs Non-Preferred Drugs
If a generic drug is requested at a You pay 20% coinsurance ($10 minimum**, $50 maximum) per covered
participating Retail Pharmacy ... prescription.
If a brand-name drug is dispensed at a You pay 30% coinsurance ($25
You pay 45% coinsurance ($50
participating Retail Pharmacy and a minimum**, $100 maximum) plus the minimum**, $150 maximum) plus the
generic drug IS available ...
cost difference between the brand-name cost difference between the brand-
and generic per covered prescription. name and generic per covered
prescription.
If a brand-name drug is dispensed at a You pay 30% coinsurance ($25
You pay 45% coinsurance ($50
participating Retail Pharmacy and a minimum**, $100 maximum) per minimum**, $150 maximum) per
generic drug IS NOT available ... covered prescription.
covered prescription.
When you use a non-participating Retail
Pharmacy ...
You pay 50% coinsurance ($50 minimum**, no maximum) of the allowed amount
per covered prescription. If a brand-name drug is dispensed and a generic drug is
available, you will also pay the cost difference between the brand-name and generic
per covered prescription.
Where applicable, taxes will be added to copayment/coinsurance amounts. In addition, all copayment/coinsurance amounts are
paid after the deductible has been satisfied.
* Additional criteria as noted throughout the “Pharmacy” section in this SPD may apply to determine whether specific
drugs are covered and in what dosage or quantity amount. Please call Medco if you have questions about coverage and/or
limitations on the quantity or dosage amount covered for a specific prescription drug.
** Or the full cost if less than the minimum.
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Retiree Health Care SPD Effective January 1, 2012
Formulary Drugs
The formulary is a list of commonly prescribed brand-name and generic drugs Medco has
designated as “preferred" based on the drug’s clinical effectiveness and opportunities to help
contain costs. You will usually receive the highest level of coverage when you use formulary
drugs. For these plans, the formulary used includes generics along with approximately one or
more brand-name drugs in a therapeutic category.
Formulary Status:
Generic = lowest cost drugs to U.S. Bank and retirees (generics)
Preferred = Moderate cost drugs to U.S. Bank and retirees (brand-name drugs on the formulary
drug list)
Non-Preferred = Highest cost drugs to U.S. Bank and retirees (brand-name drugs NOT on the
formulary drug list). Some drugs may be grouped together as Non-Preferred. Examples include
“preferred” Proton Pump Inhibitors (PPI) = Heartburn/acid reflux medications such as Nexium
and all compounded medications.
At times you may also see drugs referred to as Tiers. A tier is typically the
copayment/coinsurance level assigned to that drug as follows:
Tier 1 = usually generic drugs
Tier 2 = usually formulary (preferred) drugs
Tier 3* = usually non-preferred drugs
Tier 4* = some drug classes may be grouped into Tier 4 which include both preferred and nonpreferred
drugs (for example, PPI medications and compounded medications).
*Tier 3 and Tier 4 are both considered the highest copayment/coinsurance level.
Once enrolled, you may view the formulary (preferred) status of a medication at
www.medco.com.
Sometimes your doctor may prescribe a non-preferred medication for which either a formulary
(preferred) brand-name or generic alternative drug is available. If your doctor specifies that a
prescription be “dispensed as written” or “DAW”, the pharmacist may ask your doctor whether a
generic or an alternative formulary (preferred) drug might be appropriate for you. Only if your
doctor agrees, your prescription will be filled with the substituted or alternative drug. A
confirmation will be sent to you and your doctor explaining the change. Ask your doctor if you
have questions about a change in prescription. Your doctor always makes the final decision on
your medication, and you can always choose to keep the original prescription. Pharmacies will
dispense only the medication authorized by your doctor. NOTE: The Medco Pharmacy
(Medco’s mail order service) will automatically dispense a generic, unless your doctor
indicates “DAW” or “dispense as written” on the prescription. Other substitutions may be
made by the pharmacist after consulting with your doctor. Regardless of what your doctor
prescribes, you are responsible for the applicable copayment/coinsurance based on the
drug you receive. When applicable, if a brand-name drug is dispensed and a generic drug
is available, you will pay the brand coinsurance plus the cost difference between the brandname
and the generic per covered prescription.
Please remember that the price of prescription drugs can fluctuate, which may affect your cost
for the medication. In addition, drugs can be added to or removed from the formulary throughout
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Retiree Health Care SPD Effective January 1, 2012
the year. Note: PPI medications such as Nexium and compounded medications will be covered
at the highest brand-name drug coinsurance level of 45%. In addition, applicable coinsurance
minimum and maximums will apply. To verify whether your drug is on the formulary list, or if
there are any additional pharmacy benefit limitations, you may also call Medco at 1-800-864-
1404.
Diabetic Supply Exception
If you are enrolled in the Early Retiree Medical Option – under this exception, diabetic
supplies such as syringes, test strips, and lancets, are covered at 100% once your combined
pharmacy/medical deductible has been met when received at a participating retail pharmacy or
mail order using the Medco Pharmacy*. This exception applies to only diabetic supplies, not
diabetic medications (oral or injectable) such as insulin.
If you are enrolled in the Comprehensive, Medica or UnitedHealthcare options - under this
exception, diabetic supplies such as syringes, test strips, and lancets, are covered at 100%, no
deductible when received at a participating Retail Pharmacy or mail order using the Medco
Pharmacy*. This exception applies to only diabetic supplies, not diabetic medications (oral or
injectable) such as insulin.
*Diabetic supplies are considered a maintenance medication. Therefore, the “Mail Order Maintenance Drug
Provision” applies for all options. See the “Mail Order Maintenance Drug Provision” section in this SPD for more
information.
Mail Order Maintenance Drug Provision
Maintenance medications are those prescription drugs (including injectable and specialty
injectable drugs) taken on a long-term basis – such as those used to treat allergies, diabetes, high
cholesterol or high blood pressure. In addition, medications you take continually, such as oral
contraceptives are considered maintenance medications as well as diabetic supplies such as
syringes, test strips and lancets.
Under this provision there is a maximum retail refill allowance (RRA). This means you may fill
your maintenance medication prescription at your Retail Pharmacy for a one-month supply,
followed by one refill at your Retail Pharmacy. To continue to receive pharmacy benefit
coverage after your first two fills (does not reset per calendar year), you need to order your next
refill through the Medco Pharmacy (Medco’s mail order service). If you fill your maintenance
medication at your Retail Pharmacy after your first two fills, you will receive no coverage and
you will be responsible for the full cost of the prescription. Note: The two-fill limit does not
reset per plan year, prior applicable refills are considered*.
*At times, counting two fills can be challenging due to the vast number of medications, dosages, strengths, etc. In
addition, intermittent use or fills of a maintenance medication may impact the fill-counting logic. If you have any
questions about your medications or to determine which medications are subject to a retail refill limit, contact
Medco at 800-864-1404.
To order maintenance medications send your prescription to the Medco Pharmacy (Medco’s mail
order service) and have the medication delivered conveniently right to you.
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All plans require the use of Accredo (a division of the Medco Pharmacy for specialty drugs) for
coverage of certain specialty drugs. See the “Specialty Drug Provision” section that follows for
more information about coverage.
Specialty Drug Provision
Specialty drugs are high cost genetically engineered injectables, selected compounds, and
selected orals designed to target and treat small patient populations with chronic, often complex,
diseases, which require challenging regimens and a high level of expertise. In order to be
covered, certain specialty drugs used to treat complex conditions must be purchased through
Accredo (a division of the Medco Pharmacy for specialty drugs) for all fills of your prescription,
including your first fill. If you fill these specialty drugs at your Retail Pharmacy, you will receive
no coverage and you will be responsible for the full cost of the prescription. Examples of such
conditions include, but are not limited to: Multiple Sclerosis; Rheumatoid Arthritis; HIV/AIDS;
cancer; hepatitis B & C; hemophilia; infertility; and growth hormone deficiency. To determine
which specialty drugs are subject to these provisions, call Medco at 1-800-864-1404.
For specialty drugs, you will be charged your regular mail order coinsurance for each 30-day
increment. Some medications are dosed or packaged in a quantity/days supply that do not fall
neatly into a one month, two month, three month category or increment. When this is the case,
you will pay the applicable coinsurance once for day’s supply 1-30, the applicable coinsurance
amount twice for day’s supply 31-60, and the applicable coinsurance amount three times for days
supply 61-90.
Accredo offers an enhanced level of service over your Retail Pharmacy. Features include:
• Fast, easy service from a pharmacy dedicated solely to filling high-cost injectables,
compounds and selected oral drugs. The pharmacy calls your doctor directly to get your
prescription and to get you started on this program. Refills can be ordered by phone.
• Your medication is sent to your home or your doctor free of charge, usually within two days,
once your prescription order is received.
• All supplies such as needles and syringes are free and sent along with your medication.
• Eliminates concern over the Retail Pharmacy not having your drug in stock, a delay in
receiving your medication and repeated trips to the pharmacy.
• One-on-one member care through toll-free customer service available 24 hours a day, 365
days a year. You and your doctor can talk with specially trained staff to answer questions and
receive consultation from experienced and knowledgeable pharmacists and nurses.
• Automatic reminders, if you forget to refill, to ensure your medication gets to you on time.
Call Medco at 1-800-864-1404 and a representative will get you started and answer your
questions. They can also tell you if your drug is covered under this provision (e.g., insulin is not
considered a specialty drug), should be ordered through the Medco Pharmacy (Medco’s mail
order service) or obtained from a participating Retail Pharmacy. See the “Mail Order
Maintenance Drug Provision” section in this SPD for more information. Any prescription drug
excluded from coverage is also excluded under the Specialty Drug Provision.
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Medco’s –Mail Order Service Pharmacy
When to Use Mail Order
You should use the Medco Pharmacy (Medco’s mail order service) if you are taking a
maintenance medication for 90 days or longer to treat any ongoing health condition, such as high
blood pressure, asthma, diabetes, if you take oral contraceptives or you need diabetic supplies.
You may experience significant cost savings by taking advantage of the Medco Pharmacy rather
than a Retail Pharmacy. See the “Mail Order Maintenance Drug Provision” section in this SPD
for more information. For all options certain specialty medications require the purchase of all
fills of your medication through Accredo (a division of the Medco Pharmacy for specialty
drugs). See the “Specialty Drug Provision” section in this SPD for more information.
Supply of Medication
Subject to certain limitations as noted throughout the “Pharmacy” section in this SPD, you will
generally receive up to a 90-day supply for each prescription/refill available through the Medco
Pharmacy (Medco’s mail order service). Certain drugs are limited, however, to a set quantity –
regardless of what your doctor prescribes. The allowed amount is based on FDA-approved
dosing guidelines and medical literature or limited as per individual state regulations. Please call
Medco at 1-800-864-1404 if you have questions about coverage and/or limitations on the
quantity or dosage amount covered for a specific prescription drug.
Copayment/Coinsurance
Your copayment/coinsurance for each supply of medication depends on the option you have
selected, the type of medication you receive and when/where you obtain the medication. See the
“Pharmacy Coverage Summary” section in this SPD for more information.
Ordering Mail Order Prescriptions
Ask your doctor to prescribe up to a 90-day supply of your medication, plus refills, if necessary,
up to one year (or six months for controlled substances). Mail your prescription and required
copayment/coinsurance along with a Medco by Mail Order Form to:
Medco
P.O. Box 650322
Dallas, TX 75265-0322
To obtain an order form and pre-addressed envelope, contact Medco by phone at 1-800-864-
1404 or online at www.medco.com. Your doctor can also submit your mail order prescription on
your behalf by calling Medco at 1-888-EASYRX1 (1-888-327-9791).
Refilling your Mail Order Prescriptions
Remember to reorder on or after the refill date indicated on the refill slip or on your medication
container. If refills are authorized, a prescription may be refilled up to one year after the date it
was written. For most controlled substances, it’s up to six months or five refills, whichever is
less. If you request a refill before the allowed refill date, the pharmacy will hold your
prescription and fill it on the date the refill is allowed. You may order refills in one of three
ways:
• Refills online – Go to www.medco.com. Once registered, login and select your
prescriptions available for ordering.
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• Refills by phone – Call 1-800-864-1404. Have your member ID number from your
Medco ID card, your refill slip with the prescription number, and your credit card ready.
• Refills by mail – Use the refill and order forms provided with your medication. Mail
them with your copayment/coinsurance to:
Medco
P.O. Box 650322
Dallas, TX 75265-0322
Paying for Your Medication
You may pay by check, eCheck, money order, VISA, MasterCard, Discover/NOVUS, American
Express, Diner’s Club or debit card. Call Medco at 1-800-864-1404 or TTY/TDD (for the
hearing impaired) at 1-800-759-1089.
If your account balance is over $150 and you do not have a credit or debit card on file, Medco
will contact you for payment arrangements. If your account balance is over $500 and you do
have a credit or debit card on file, Medco will contact you for authorization to bill the credit or
debit card.
Authorization of Payment. When an order is received at the pharmacy and is in the input area,
the credit card will be authorized for the cost of the order. The actual charge to the credit card
occurs when the order is shipped.
Order requested through the mail. When an order is requested through the mail, the system
will charge the credit card that is noted as the preferred card. If you include updated billing
information with the order, the input technician will update the system.
Order placed through the IVR. When you request a refill through the phone system, you are
given the option of charging the preferred card or selecting a different card for one-time use. You
also have the option of changing or adding a card to your billing information.
Order placed through the Web. You have the option of adding or updating credit card
information through the Web site, including the enrollment or cancellation of your participation
in the Auto Charge Program at any time.
Order placed by phone. You may request a one-time charge to your credit card or you may
choose to enroll in Medco’s Auto Charge Program. The Auto Charge Program enables Medco to
keep a credit card on file to charge automatically without you having to call and provide
authorization each time. You may enroll or request cancellation of your participation in the Auto
Charge Program at any time by calling Medco at 1-800-864-1404.
Unpaid member accounts: U.S. Bank is committed to paying all eligible prescription drug
claims incurred under the terms of the Program with Medco chosen as the pharmacy Claims
Administrator. If a Medco member account is not paid timely, U.S. Bank will be notified. Past
due account balance billings will be first sent by Medco. If after several attempts to collect, the
member account remains unpaid, U.S. Bank will be required to satisfy the balance. Should U.S.
Bank pay an account balance on behalf of an enrolled member, the delinquent account holder
will be notified, at that time, and U.S. Bank will advise of their right to collection. Such account
holders (including covered family members) will also lose their right or privilege of future
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billings and will be required to “pay as you go”. All account inquiries should be directed to
Medco by calling 1-800-864-1404. Also see the “Recovery of Excess Payments and Correction
of Errors” section in this SPD for more information.
Delivery of Your Medication
Your address within the Shipping Information on your profile is populated and updated by U.S.
Bank’s enrollment and eligibility process. Prescription orders may also be sent using the address
provided by you under the Shipping Information section of the Medco by Mail Order Form. If
you need to verify or update this address, call Medco at 1-800-864-1404 or access your profile
online at www.medco.com.
Prescription refill orders are usually sent to you by U.S. mail in about a week. (Please allow 14
to 21 days turnaround time for an initial order.) Overnight delivery is available for an additional
charge. Your enclosed medication will include instructions for refills, if applicable. Your
package may also include information about the purpose of the medication, correct dosages and
other important details.
Note:
• The pharmacist's judgment and dispensing restrictions, such as quantities allowable,
govern certain controlled substances and other prescribed drugs. Medco prohibits the
return of all dispensed drugs.
• Prescription orders will not be filled more than 12 months after issuance, more than six
months after issuance for controlled drug substances or if prohibited by applicable law or
regulation.
Due to certain situations, Medco may need to split your order to avoid delaying receipt of your
medications. Some of these situations might include:
• When there are multiple prescriptions written on the same prescription slip and additional
information from the doctor or member is needed;
• When a member sends in multiple prescription requests on separate forms but one
medication may be for a controlled substance that might need to be dispensed from a
different location due to state mandates or regulations;
• A specific medication may be on backorder; or
• One of the medications may be subject to additional review.
Members are notified of split orders on the statement that is sent by the Medco Pharmacy with
their mail order. Split orders may impact the refill dates. It is always important to check the
refill/renewal dates on each prescription.
How to Place a Successful Mail Service Order
1. For new prescriptions: Medco recommends that your physician write out two prescriptions:
• A short-term script (up to 31 days) that can be filled at a Retail Pharmacy. This gives you
up to 31 days of medication while completing and mailing the order forms and waiting
for the initial shipment.
• A long-term prescription written for a 90-day supply with three refills. Mail this
prescription along with the Medco by Mail Order Form to the Medco Pharmacy
(Medco’s mail order service). This prescription will usually offer a full year supply
before a new prescription must be obtained.
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• Prescriptions are not held by Medco. Once a prescription is received, it will be processed
per the guidelines of this Program.
2. Be sure the strength, dosage and instructions are on the prescription and that it is clearly
legible. Class II Controlled Substance medications (which require a new prescription with
each fill) have special mandated requirements. Examples include pain control medications
(e.g. Percocet, Demerol, oxycodone, or morphine), attention deficit disorder medications
(e.g. Ritalin, Adderall, or Concerta), and miscellaneous agents (e.g. Dexedrine). Please check
with your doctor for specific state requirements for Class II Controlled Substance
medications, including whether the doctor needs to include the diagnosis code on the face of
the prescription. The Medco Pharmacy will automatically dispense a generic, unless your
doctor writes “DAW” or “dispense as written” on the prescription. Other substitutions or
alternative (preferred) drugs may also be made by the pharmacist after consulting with your
doctor.
3. Write the member’s name and member ID number found on the Medco ID card on the back
of the original prescription.
4. Complete the Personal Information section of the Medco by Mail Order Form. This section is
essential and must be completed the first time a member utilizes the Medco Pharmacy. It
allows patients to share any allergies or medical conditions so that the pharmacist can
conduct a thorough drug utilization to ensure patient health and safety. Be sure that the
member’s ID number is clearly seen at the top left corner of the form.
5. Complete each section of the Medco by Mail Order Form. Be sure to provide a shipping
address. Medco can ship orders to different locations within the United States as requested.
Please provide a daytime phone number in the event a pharmacist needs to reach someone.
6. Enclose your credit card information or a check for the correct copayment/coinsurance with
the order. If you are uncertain what the copayment/coinsurance will be, call Medco at 1-800-
864-1404. A representative will be able to confirm the amount.
7. Allow up to 14-21 days turnaround time on the initial order. The initial order will always
take a little longer as Medco needs to enter profile information into the member’s family
history account. In addition, they may have to confirm new prescription(s) with your doctor
if they have a question. Subsequent refills typically take one week to ship.
8. You cannot cancel an order once it has been placed.
Frequently Asked Mail Order Questions
Can mail order prescriptions be faxed?
Yes, your doctor can fax prescriptions for up to a 90-day supply to the Medco Pharmacy (Medco’s
mail order service) if he/she is willing to do so. However, faxing a prescription will not necessarily
reduce the overall time it takes for you to receive an order. Your doctor should call 1-888-EASYRX1
(1-888-327-9791) and follow the prompts for fax submission. The doctor must include the following
information along with the prescription(s): Patient’s name and date of birth, member’s ID number
found on the Medco ID card, doctor’s name, office phone number and fax number, time and date,
doctor’s address, doctor’s DEA number, doctor’s signature, and complete name of the person faxing
the prescription. If it’s incomplete or missing, Medco will fax the prescription back to the doctor
requesting the necessary information. Please note that some states (such as New York) do not allow
the faxing of controlled substance prescriptions.
Can I order or request easy open caps on my medication bottles?
Safety caps are required by law on medication bottles whenever medication is being shipped. If you
would like Medco to send easy open caps along with your prescriptions, indicate that request on your
order.
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How are temperature-sensitive materials shipped?
These types of medications are packaged in insulated packaging appropriate for the medication being
shipped. It will be shipped either next day or second day depending upon the medication needs.
What if my doctor writes my prescription for a 30-day supply?
Medco cannot dispense a quantity greater than what was written by your doctor, even though your
pharmacy mail order benefit allows up to a 90-day supply.
Why did I receive a drug other than what was prescribed by my doctor?
Medco may substitute a generic medication or alternative formulary (preferred) for the brand-name
medication originally prescribed by your physician. When a substitution is made, you will receive a
letter describing that substitution.
If you have any questions about the medication you receive, you may contact Medco at 1-800-864-
1404 and speak with a pharmacist.
What happens if I return my medication to Medco?
The medication will be destroyed by Medco and you will be responsible for the copayment.
Medco cannot restock returned medication.
Education and Safety
You will receive information about critical topics like drug interactions and possible side effects
with every new prescription mailed to you. By visiting www.medco.com, you also can access
other health-related information. Any written health information cannot replace the expertise and
advice of health care providers who have direct contact with a patient. All Medco health
information is designed to help you communicate more effectively with your doctor and, as a
result, understand more completely your situation and choices.
Retail Pharmacy
When to use a Retail Pharmacy
You are encouraged to use a Retail Pharmacy when you need a prescription on a short-term basis
only – for example, an antibiotic to treat strep throat or if your prescription is covered by
Medicare Part B (see section titled “When You Have Other Coverage – Medicare Part B
Program”). For medications needed longer than short-term, see the “Mail Order Maintenance
Drug Provision” and “Specialty Drug Provision” sections in this SPD for more information.
Supply of Medication
Subject to certain limitations as noted throughout the “Pharmacy” section in this SPD, you will
generally receive the prescribed amount, up to a 31-day supply. Certain drugs are limited,
however, to a set quantity – regardless of what your doctor prescribes. The allowed amount is
based on FDA-approved dosing guidelines and medical literature or limited as per individual
state regulations. Please call Medco at 1-800-864-1404 if you have questions about coverage
and/or limitations on the quantity or dosage amount covered for a specific prescription drug.
Copayment/Coinsurance
Your copayment/coinsurance for each supply of medication depends on the option you are
enrolled in, the type of medication you receive and when/where you obtain the medication. See
the “Pharmacy Coverage Summary” section in this SPD for more information.
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Finding a Participating Pharmacy
The majority of pharmacies and pharmacy chains in the United States are in Medco's
participating pharmacy network. However, the network is subject to change throughout the year.
It is your responsibility to verify that the pharmacy you or a covered family member uses is in
Medco’s network. Prior to receiving a prescription, you should call Medco at 1-800-864-1404 to
find a participating pharmacy or to find out if a specific pharmacy continues to be part of their
network. This information can also be accessed online at www.medco.com.
Ordering Prescriptions at a Participating Pharmacy
You need to present your Medco ID card and prescription(s) written for up to a 31-day supply to
the pharmacist (except when ordering prescriptions covered by Medicare Part B; see “Medicare
Covered Drugs” section). Your ID card is good at any participating pharmacy nationwide. His or
her computerized system will confirm your eligibility for benefits. The pharmacist will tell you
the coinsurance you are required to pay. You do not have to file a claim form for prescriptions
filled at a participating network pharmacy when you show your Medco ID card. However, if the
pharmacist is unable to fill your prescription for reasons, such as ineligibility for benefit or denial
of prior authorization, you disagree with the coinsurance amount charged by the pharmacist or
the manner in which your prescription was filled, you need to file a claim with Medco for
reimbursement consideration (up to a 31-day supply). If you use a participating pharmacy, but do
not show your Medco ID card, you will also need to file a claim with Medco. Any eligible
reimbursement will be reduced in this situation. Refer to the “Filing Pharmacy Claims – Medco”
section in this SPD for more information.
If you are purchasing a “compounded prescription” drug (which requires a pharmacist to
specially mix one or more prescription drugs together into a final product), your pharmacist may
not be able to submit the claim to Medco using the online system. In this case, ask your
pharmacist to submit the claim using a Universal Claim Form. For claims not submitted to
Medco by the pharmacist, you will need to pay the full cost of the compounded prescription drug
(up to a 31-day supply) and file a claim yourself with Medco. Upon receipt, Medco will
determine if your compounded prescription drug is covered. A combination of two or more overthe-counter
medications would not be considered a compounded prescription drug. There must
be at least one covered prescription drug included to make it a reimbursable item. Any eligible
reimbursement will be significantly reduced in this situation. Refer to the “Filing Pharmacy
Claims – Medco” section in this SPD for more information.
Ordering Prescriptions at a Non-participating Pharmacy
You must pay the full cost of the prescription at the time of purchase and submit a completed
claim form to Medco. Your reimbursement (up to a 31-day supply) will be significantly less than
what a participating pharmacy would charge. Refer to the “Pharmacy Coverage Summary”
section and the “Filing Pharmacy Claims – Medco” section in this SPD for more information.
Prior Authorization for Pharmacy Coverage
Coverage for some drugs is only available if they are prescribed for certain uses. For this reason,
some medications must receive prior authorization before they can be covered under this
Program. If the prescribed medication must be prior authorized, your retail pharmacist or Medco
Pharmacy (Medco’s mail order service) representative should inform you. You will need to ask
your doctor or pharmacist to call the Medco Prior Authorization Line at 1-800-753-2851. This
line is only available to doctors and pharmacists and not Medco’s members. The prior
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authorization review process can generally be completed during the phone call with your doctor
or pharmacist. However, if additional information is needed before a decision can be reached, the
process can typically take two business days. The patient and doctor will be notified when the
review process is completed. If your medication is not approved for coverage, you will receive
no coverage and you will be responsible for the full cost of the drug. Following is a list of drugs
that require prior authorization. This list is subject to change without notice. To verify whether
your drug requires Prior Authorization, contact Medco at 1-800-864-1404.
• Acthar Gel
• Androgens and anabolic steroids (such as Androderm, testosterones, etc.)
• Anti-interleukins (such as Arcalyst and Ilaris)
• Anti-narcoleptic agents (such as Provigil)
• Anti-obesity (weight loss) agents
• Antibiotic - Solodyn
• Avita, Differin, Retin-A and Tazorac (for patients over 29 years old)
• Botulinum Toxin (Botox, Myobloc)
• Cancer medications
• Chenodal
• CNS stimilants/Strattera
• Epogen, Procrit, Aranesp
• Goucher Disease agents (such as Vpiv and Zavesca)
• Growth stimulating agents and receptor antagonists
• Infertility drugs – injectable (e.g., Fertinex, Pergonal, Metrodin, Factrel, Repronex, Gonal-f,
Follistim, Profasi, Gonadorelin acetate (Lutrepulse))
• Neurological agents (such as Xenazine)
• Osteoporosis therapy drugs
• Parkinsons therapy drugs
• Psoriasis agents (such as Amevive and Stelara)
• PKU agents (such as Kuvan)
• PNH agents (such as Soliris)
• Pulmonary agents (such as Berinert, Cinryze Kalbitor and Xolair)
• Regranex
• Relistor
• Second line step therapy drugs
• Topical pain agents (e.g., Voltaren Gel, Flector Patch)
• Vaginal fertility agents (Crinone 8% gel)
• Xgevea
Step Therapy
When multiple drugs are available for treating a medical condition, often it is useful and more
cost-effective to follow a step-wise process to find the best treatment for an individual. This
process is called “step therapy.” Medco administers your prescription drug benefits on behalf of
U.S. Bank and utilizes the step therapy program for conditions with many drug therapy choices
in order to control costs.
The step therapy program evaluates opportunities where certain first-line drugs should be tried
before the cost of other, often more expensive medications are covered. Through the
administration of the step therapy program, the pharmacist is informed via online messaging
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Retiree Health Care SPD Effective January 1, 2012
when a medication you are taking qualifies for the step therapy program. In some situations, the
step therapy medication may be covered automatically if your medication history shows you
have tried a formulary (preferred) medication some time in the past. If not automatically covered,
a toll-free number is provided via the online messaging, in which your pharmacist (or you) can
initiate the review process necessary to allow coverage for your medication identified as part of
the step therapy program. In some situations your doctor may decide to change your prescription
to the less costly formulary (preferred) medication after discussing options with the Medco step
therapy area.
Some conditions/medications that require step therapy include pain/arthritis, high blood pressure,
osteoporosis, hypnotic sleep medications, depression, cholesterol lowering agents, rheumatoid
arthritis, psoriasis, cancer specialty medications, narcotic pain medications, intranasal steroids,
migraine headache – triptan medications, sensipar, pulmonary arterial hypertension agents,
gastrointestinal acid-peptic disorders, Gaucher’s agents and Gout medications. This is not
intended to be an exhaustive list and is subject to change without notice.
In addition, refer to the “Prior Authorization for Pharmacy Coverage” section in this SPD for
additional information.
Frequently Asked Questions About Step Therapy
Why should use of second-line drugs be limited?
Second-line drugs may have more side effects, be more difficult to take, and/or be more
expensive than their first-line alternatives.
Can I get coverage for a second-line drug even if I have not tried a first-line drug?
In some cases, the answer is yes. Exception processes are available for the rare cases in which no
first-line drug is appropriate. If you meet certain medical criteria, you may be able to get
coverage through the prior authorization process. Refer to the “Prior Authorization for Pharmacy
Coverage” section in this SPD for additional information.
Does a change to a first-line drug have to be approved by my doctor?
Yes, because it involves a change to the drug being dispensed. No prescriptions will
automatically be changed based on the step therapy program.
If my prescription is changed, will my copayment/coinsurance also change?
Your copayment/coinsurance may be lower. In many cases, the first-line drug is a generic and
therefore has a lower copayment/coinsurance than the second-line drug, which is typically a
brand-name product.
How are first- and second-line drugs chosen?
Medco’s independent Pharmacy and Therapeutics Committee of pharmacists and doctors select
the first- and second-line drugs after careful review of medical literature, manufacturer product
information, and consultation with medical professionals. These steps are taken to make sure that
the protocols reflect the most current and appropriate drug therapy recommendations.
If you have specific questions about step therapy and how it may affect your prescription drugs,
call Medco at 1-800-864-1404. You also may visit www.medco.com for general and
personalized prescription drug information.
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Additional Pharmacy Benefit Limitations
There are additional criteria, such as safety and cost, that are considered in determining which
drugs are covered under the pharmacy benefit and in what amount or dosage. Examples of these
limitations include:
• Brand-name and generic drugs – The brand name of a drug is the product name under
which the drug is advertised and sold. Many brand-name medications have become well
known through advertising. Generic medications are sold under generic, often unfamiliar,
names. The U.S. Food and Drug Administration (FDA) requires FDA-approved generics to
have the same active ingredients and are subject to the same rigid FDA standards for quality,
strength and purity as their brand-name counterparts. You must use generic drugs if they are
available for your condition in order to receive the highest level of benefits. If a brand-name
drug is dispensed when a generic equivalent is available – whether requested by you or your
doctor – you will pay the cost difference between the brand-name and generic medications,
plus your brand-name coinsurance.
• Quantity limits – In most cases, when you fill a prescription you will receive the prescribed
amount, up to a 31-day supply through the Retail Pharmacy or up to a 90-day supply through
the Medco Pharmacy (Medco’s mail order service). Certain drugs are limited, however, to a
set quantity – regardless of what your doctor prescribes. The allowed amount is based on
FDA-approved dosing guidelines and medical literature or limited as per individual state
regulations. Examples of drugs with quantity limits are medications for high blood pressure,
cholesterol, diabetes, asthma, osteoporosis, depression, pain, ulcers, allergies, gout, psoriasis,
Alzheimers and Multiple Sclerosis, Parkinson’s, Rheumatoid Arthritis, migraine products
(e.g., Imitrex), hypnotic sleep medications, antifungal agents, TOBI, Acthar Gel, erectile
dysfunction agents (e.g., Viagra), pulmonary arterial hypertension agents, cancer
medications, antivirals, interferons, anti-emetics, estrogens, and RSV agents. However, these
are only examples and not an exhaustive list.
• Lifetime maximums – Certain drugs are limited to a set lifetime maximum – regardless of
what your doctor prescribes. Examples of drugs with lifetime maximum limits are
prescription medications for the treatment of infertility. The lifetime maximum may be
reached by intermittent or continuous drug therapy. Once satisfied, no further benefits will be
payable. For more information refer to the “Infertility Coverage Maximum” section in this SPD.
• Proton Pump Inhibitors (PPI) – Branded PPI medications (heartburn/acid reflux
medications) such as Nexium will be covered at the highest brand-name drug coinsurance
level of 45%. In addition, applicable coinsurance minimum and maximums will apply.
• Compounded Medications – Compounded medications (when covered) will be paid at the
highest coinsurance level of 45%. In addition, applicable coinsurance minimum and
maximums will apply.
Please contact Medco at 1-800-864-1404 or visit www.medco.com if you have questions about
coverage and/or limits for a specific prescription drug.
Infertility Coverage Maximum
A $7,500 lifetime maximum per family (not per person) applies to all infertility prescription
drugs. A separate $2,500 lifetime maximum per family (not per person) applies to all infertility
services, including medical and surgical treatment. Refer to “Infertility Treatment” under “What
the Options Cover” section in this SPD for more information.
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Retiree Health Care SPD Effective January 1, 2012
Vaccines Covered by Medicare Part D
If you are enrolled in UnitedHealthcare or Medica, vaccines that are covered by Medicare Part D
are not covered by these medical carriers. However, these vaccines (such as the vaccine for
Shingles) will be covered by Medco if the prescription is filled at a participating network retail
pharmacy.
You should inform your physician that the vaccine is not covered by your medical carrier
(UnitedHealthcare or Medica). You will need to coordinate with both your physician and the
pharmacist at the Retail Pharmacy to ensure that the pharmacy stocks the particular vaccine, and
has someone onsite that can administer the medication.
Drugs Not Covered
The following drugs/supplies are specifically not covered under the Pharmacy Care Program:
• Allergy serums
• Biologicals, immunization agents or vaccines (except vaccines covered by Medicare D
• Blood or blood plasma products
• Blood glucose monitors
• Dental fluoride products
• Experimental, investigative or unproven drugs/agents
• Glucowatch products
• Medications for cosmetic purposes, such as Renova, Propecia, Vaniqa and Botox
Cosmetic, except when Prior Authorization is established (see “Prior Authorization for
Pharmacy Coverage” in this section)
• Medications not approved by the FDA
• Mifeprex
• Non-sedating antihistamines such as Zyrtec, Zyrtec-D, Allegra, Allegra-D, Clarinex,
Clarinex-D and Fexofenadine
• Non-systemic contraceptive, devices – such as IUDs and diaphragms
• Ostomy supplies
• Over-the-counter medications or over-the-counter equivalents
• Relenza
• Smoking cessation products
• Tamiflu
• Therapeutic devices or appliances
• Yocon
• Yohimbine
Some of the items listed above may be covered under your health care option. To receive
coverage, the claim should be submitted to your medical Claims Administrator.
This is not intended to be an exhaustive list and is subject to change without notice. If you have
any questions, call Medco at 1-800-864-1404.
Filing Pharmacy Claims – Medco
You do not file claims when you use the Medco Pharmacy (Medco’s mail order service) or
use a participating Retail Pharmacy and show your Medco ID card. However, you are
responsible for paying any applicable deductibles, copayments or coinsurance.
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Retiree Health Care SPD Effective January 1, 2012
You will need to pay for the prescription in full at the time of purchase and then file a
claim with Medco if:
• you receive services from a participating Retail Pharmacy, but don’t show your Medco
ID card;
• you use a non-participating Retail Pharmacy; or
• you receive a compounded prescription drug that the pharmacy didn’t submit to Medco.
Claim forms are available by calling Medco at 1-800-864-1404 or online at www.medco.com.
To be eligible for payment, claims must be received within 12 months from the date of service.
Be sure to include your name, the patient’s name and the member ID from your Medco ID card.
Send your original receipt (making a copy for your records) along with a completed Medco
claim form to:
Medco Health Solutions
P.O. Box 14711
Lexington, KY 40512
Upon receipt, Medco will process your claim. Your reimbursement will be based on the
allowed amount had you used a participating Retail Pharmacy and presented your Medco
ID card, minus your responsibility of 50% coinsurance ($50 minimum, no maximum); or
the full cost if less than the minimum. You will be responsible for any amounts that exceed
the allowed amount. In addition, Medco will apply any additional criteria/provisions that
your medication would have been subject to as noted throughout the “Pharmacy” section
in this SPD. You will receive an Explanation of Benefits (EOB) within 30 days of receiving
your claim.
For information on filing medical claims, see the “Filing Health Care Claims – BCBS” section in
this SPD.
When You Have Other Coverage – Medco
If you or your dependents are covered by a U.S. Bank option and by another group health plan,
the U.S. Bank option will not coordinate its payment for pharmacy-related expenses with those
of the other group plan. Therefore, at the time a prescription order is placed (retail or mail order)
and you use the U.S. Bank Medco ID card, the U.S. Bank option will pay as primary. If you use
the pharmacy ID card from the other group plan, no further benefits will be considered for
payment from the U.S. Bank option. The same would apply if you or your dependents are
covered by one of these options along with participation in various other health plans/programs
(i.e., Medical Assistance program, State Agency program, Medicaid, etc.).
For information related to medical services, see the “When You Have Other Coverage – BCBS”
section in this SPD.
When You Have Other Coverage – Medicare Part B Program
Medicare Covered Drugs
Certain drugs and supplies are covered by Medicare Part B including diabetic supplies, nebulizer
solutions, certain immunosuppressant drugs used post-transplant and certain oral anti-cancer
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Retiree Health Care SPD Effective January 1, 2012
drugs. If you are currently eligible for Medicare Part B coverage, the Program will coordinate
with Medicare Part B. If you wish to submit prescriptions for Medicare Part B-eligible drugs to
Medicare, you will need to go to a Retail Pharmacy that is a “Medicare supplier” and present
your Medicare card. The Retail Pharmacy will need to submit these claims to Medicare on your
behalf as noted below:
• At Retail: When using a Retail Pharmacy, you will be asked to present your Medicare ID
card. The Retail Pharmacy will work with you to bill Medicare on your behalf. The Retail
Pharmacy will also submit any other claims that may be eligible for additional coverage.
Most independent pharmacies and national chains are Medicare suppliers.
• At Mail: Medco Pharmacy (Medco’s mail order service) is not a Medicare supplier;
therefore if you submit your prescription to Medco Pharmacy, the Program will not
coordinate your benefit with Medicare.
Cost of your medication: You will be required to pay your copayment/coinsurance as
determined by your pharmacy option. If you go to a “Medicare supplier” and Medicare pays your
claim, you could also be reimbursed for additional costs not paid by Medicare. To determine if
your option will pay any additional costs not paid by Medicare, ask your pharmacist to
electronically submit the additional costs to Medco for processing under your U.S. Bank
Program option. If using a Retail Pharmacy you must use a Medco participating Retail Pharmacy
that will submit your secondary claim electronically to determine if you are eligible for
additional benefits. Paper claims sent to Medco will not be eligible for any additional
reimbursement.
If it is determined that the medication or product is not eligible for coverage under Medicare Part
B, normal provisions associated with your option will apply. Refer to the “Mail Order
Maintenance Drug Provision” section and the “Specialty Drug Provision” section in this SPD for
more information.
Any prescription excluded from coverage is also excluded under the Medicare Part B Program.
This program is subject to change. If you have any questions, please contact Medco at 1-800-
864-1404.
Health Management Program
Health Management Program participants generally receive educational mailings and toll-free
phone access to registered pharmacists. In some programs, participants may also receive followup
calls from Medco’s pharmacists. Medco develops these voluntary programs to support your
doctor's care and may contact your doctor regarding your eligibility for, or participation in, these
programs.
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BCBS OF MN OPTIONS – GENERAL
INFORMATION
The information in this section applies to the Early Retiree Medical and Comprehensive options.
Special rules that apply to the different options are noted.
Note: This section does not apply to the Kaiser Colorado, UnitedHealthcare or Medica Plan
options. If you are enrolled in the Kaiser, UnitedHealthcare or Medica Plan options, you should
refer to the materials provided to you by Kaiser, UnitedHealthcare or Medica to determine the
provisions and requirements of those benefit options.
Your ID Card
After you enroll for coverage, you will generally receive two ID cards (medical and pharmacy)
from your Claims Administrator, sent directly to your home address. You must present the
applicable ID card when receiving services, so your claim will be handled promptly. If you do
not, you may need to pay for services yourself and file a claim for reimbursement. Additional or
replacement cards can be obtained by contacting the applicable Claims Administrator.
Bariatric Surgery
Coverage is limited to bariatric surgery for severe or morbid obesity. To be eligible, certain
requirements must be met and prior approval from BCBS must be received. For severe obesity,
the Body Mass Index (BMI) must be 35-40 and will only be considered when there is
documentation of a co-morbid condition such as hypertension refractory to standard drug
regimens, cardiovascular disease, degenerative joint disease or diabetes. For morbid obesity, the
BMI must be 40 or greater.
All bariatric surgeries must be performed at a hospital or facility that participates in the Bariatric
Centers of Excellence program associated with BCBS. Services performed at nonparticipating
bariatric centers are not covered even if the services are medically necessary
and/or referred. Other benefit limits and restrictions apply.
For members age 18 and older, all bariatric surgeries must be received at a Blue Distinction
Centers for Bariatric Surgery ® . You may view a listing of designated centers at
www.bluecrossmn.com/usb. Once you locate a designated center, you need to confirm the
designated center is participating in your applicable network. To do this, choose your applicable
network from the drop down menu under “Network” and search for the designated center to
make sure it displays. You may also get information by calling BCBS Customer Service at
651-662-5550 or 1-800-729-3039 for more information.
Expenses for Travel and Lodging
Expenses for travel and lodging for the patient and a companion are available as follows:
• Transportation of the patient and one companion who is traveling on the same day(s) to
and/or from the site of the surgery for the purposes of an evaluation, the surgical procedure
or necessary post-discharge follow-up.
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Retiree Health Care SPD Effective January 1, 2012
• Reasonable and necessary expenses for lodging for the patient (while not hospitalized) and
lodging only for one companion. Expenses are reimbursed at a per diem rate of up to $50 for
one person or up to $100 for two people.
• Travel and lodging expenses are available only if the patient resides more than 50 miles from
the designated bariatric facility.
• If the patient is a covered dependent minor child, the transportation expenses of two
companions will be covered and lodging expenses will be reimbursed up to the $100 per
diem rate.
There is a combined overall lifetime maximum of $1,500 paid by the Program per covered
person for all transportation and lodging expenses incurred by the patient and companion(s) and
reimbursed under this Program in connection with the surgery. Note: The deductible must be met
by members enrolled in the Early Retiree Medical option before these expenses can be
reimbursed by the Program.
Cardiac Care
The Blue Distinction Centers for Cardiac Care ® is available for members 18 and older for health
care options administered by BCBS. This national network includes facilities that have
demonstrated their commitment to quality care, resulting in better overall outcomes for cardiac
patients. Blue Distinction Centers for Cardiac Care ® provide a full range of cardiac care
services, including inpatient cardiac care, cardiac rehabilitation, cardiac catheterization and
cardiac surgery (including coronary artery bypass graft surgery).**
You are not required to use facilities in the Blue Distinction Centers for Cardiac Care ® network
regardless of whether it’s an emergency situation or not. Benefits for lodging and travel are not
available when using these types of centers. You may view a listing of designated centers at
www.bluecrossmn.com/usb. Once you locate a designated center, you need to confirm the
designated center is participating in your applicable network. To do this, choose your applicable
network from the drop down menu under “Network” and search for the designated center to
make sure it displays. You may also get information by calling BCBS customer service (see the
“Important Resources” section in this SPD).
** At the discretion of the local BCBS Plan and under a specified contingency process, a facility that provides the
full range of cardiac services but does not provide on-site coronary artery bypass graft (CABG) surgery may be
considered for Blue Distinction designation if it is part of a cooperative system with a qualifying facility that
provides emergency backup CABG for percutaneous coronary intervention (PCI) and meets contingency criteria.
Blue Distinction Centers for Cardiac Care without on-site CABG will be differentiated from full-service Blue
Distinction Centers for Cardiac Care in program listings.
Complex and Rare Cancers
The Blue Distinction Centers for Complex and Rare Cancers® is available to members 18 and
older for health care options administered by BCBS. This national network includes facilities
that were evaluated on patient assessment, treatment planning, complex inpatient care and major
surgical treatments for adults; all delivered by teams with distinguished expertise and
subspecialty training for complex and rare cancers. The program focuses on the following 13
cancers:
• Bladder cancer
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Retiree Health Care SPD Effective January 1, 2012
• Brain cancer – primary
• Esophageal cancer
• Gastric cancer
• Liver cancer – primary
• Pancreatic cancer
• Rectal cancer
• Acute leukemia (inpatient, non-surgical)
• Bone cancer – primary
• Head and neck cancers
• Ocular melanoma
• Soft tissue sarcoma
• Thyroid cancer – medullary or anaplastic
You are not required to use facilities in the Blue Distinction Centers for Complex and Rare
Cancers ® network. Benefits for lodging, and travel are not available when using these types of
centers. You may view a listing of designated centers at www.bluecrossmn.com/usb. Once you
locate a designated center, you need to confirm the designated center is participating in your
applicable network. To do this, choose your applicable network from the drop down menu under
“Network” and search for the designated center to make sure it displays. You may also get
information by calling BCBS customer service (see the “Important Resources” section of this
SPD).
Emergency Care
Before the need arises, be prepared for the possibility of an emergency.
• Find out about your doctor’s or clinic’s procedures for care needed after regular clinic hours.
• Write down the telephone numbers of the clinic’s after-hours service and the nearest hospital.
Your phone book should also list telephone numbers to call in case of an emergency. Keep
this information in an accessible location in case an emergency arises.
• Share this information and the BCBS phone number on your ID card with family members so
they can call if you are unable to do so.
• In the event of an emergency — you should go to the nearest emergency facility, even if it
is an out-of-network or a non-participating facility.
• Remember, you or a covered family member must call BCBS within 48 hours of
hospitalization due to an emergency.
Follow-up care for emergency services (for example, suture removal) is a non-emergency service
and must be provided by a PPO provider (for the Early Retiree Medical option), or a BCBS
"participating provider" (for the Comprehensive option) in order to be covered at the highest
level.
Knee and Hip Replacements
In order to receive the highest level of benefits, use of a Blue Distinction Center for Knee and
Hip Replacements SM is required for members age 18 and older for Health Care plans
administered by BCBS. This national network includes facilities that demonstrate an expertise in
quality care, resulting in better overall outcomes for patients, by meeting objective clinical
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Retiree Health Care SPD Effective January 1, 2012
measures developed with input from expert physicians and medical organizations. Blue
Distinction Centers for Knee and Hip Replacements SM provide comprehensive inpatient knee and
hip replacement services, including total knee replacement and total hip replacement surgeries.
You may view a listing of designated centers at www.bluecrossmn.com/usb. Once you locate a
designated center, you need to confirm the designated center is participating in your applicable
network. To do this, choose your applicable network from the drop down menu under “Network”
and search for the designated center to make sure it displays. You may also get information by
calling BCBS customer service (see the “Important Resources” section in this SPD).
Expenses for Travel and Lodging
Expenses for travel and lodging for the patient and a companion are available as follows:
• Transportation of the patient and one companion who is traveling on the same day(s) to
and/or from the site of the surgery for the purposes of an evaluation, the surgical procedure
or necessary post-discharge follow-up.
• Reasonable and necessary expenses for lodging for the patient (while not hospitalized) and
lodging only for one companion. Expenses are reimbursed at a per diem rate of up to $50 for
one person or up to $100 for two people.
• Travel and lodging expenses are available only if the patient resides more than 50 miles from
the designated facility.
There is a combined overall lifetime maximum of $1,500 paid by the Program per covered
person for all transportation and lodging expenses incurred by the patient and companion(s) and
reimbursed under this Program in connection with the surgery. Note: The deductible must be met
by members enrolled in the Early Retiree Medical option before these expenses can be
reimbursed by the Program.
Inpatient Maternity Care
Under the Newborns’ and Mothers’ Health Protection Act of 1996, group health plans providing
maternity benefits, may not restrict benefits for a hospital stay in connection with childbirth to
less than 48 hours following a vaginal delivery or less than 96 hours following Cesarean section
delivery.
You cannot be required to obtain preauthorization from your Program option in order for your
48-hour or 96-hour stay to be covered. However, authorization is required beyond the applicable
48-hour or 96-hour stay. (See the sections “Preadmission Notification and Prior Authorization
for BCBS-Administered Benefits,” in this SPD for more information.)
The law allows you and your baby to be released earlier than these time periods only if the
attending provider decides, after consulting with you, that you and your baby can be discharged
earlier. In any case, the attending provider cannot receive incentives or disincentives to discharge
you or your baby earlier than 48 hours (or 96 hours).
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Retiree Health Care SPD Effective January 1, 2012
Mental Health and Substance Abuse Coverage
For mental health and substance abuse services, refer to the “Preadmission Notification and Prior
Authorization for BCBS-Administered Benefits” section in this SPD to see if any action is
recommended or required on your part before receiving services.
Covered Services
The following services are generally covered:
• Outpatient Services – Coverage is provided for visits in an outpatient or office setting.
However, outpatient family therapy is only covered if part of a recommended treatment plan
and patient is under the age of 18.
• Day Treatment – Day treatment is defined as an outpatient program of three to five billable
hours in a day. The program services may be delivered outside of a hospital-based program.
• Inpatient Services – Coverage is provided for a semiprivate room, meals, services of a
health professional, general nursing care, and ancillary services and supplies.
• Residential Treatment Facility – Coverage is provided in a licensed residential treatment
facility.
• Partial Hospitalization – Partial hospitalization is a hospital-based program of six or more
billable hours in one day and is an alternative to inpatient care.
• Court-Ordered Treatment – Services are considered medically necessary and coverage is
provided for mental health and substance abuse care that is based on an evaluation and
recommendation for such treatment or services by a physician or a licensed psychologist, a
licensed alcohol and drug dependency counselor or a certified substance abuse assessor. An
initial court-ordered exam for a dependent child under the age of 18 is also considered
medically necessary. Court-ordered treatment for mental health and substance abuse care that
is not based on an evaluation and recommendation as described above will be evaluated to
determine medical necessity. Court-ordered treatment will be covered if it is determined to be
medically necessary and otherwise covered.
• Autism – Coverage is provided at the same level as other mental health services. Physical,
occupational, and speech therapy services for autism will process under the “Physical,
Occupational and Speech Therapy” benefits listed in the “What the Options Cover” chart.
• Eating Disorders – Coverage is provided at the same level as other mental health services.
Registered dietician services for eating disorders will process under the
“Physician/Professional Services” benefit listed in the “What the Options Cover” chart.
Mental Health
Services for mental health must be provided by a licensed medical doctor, psychologist, social
worker or other master prepared therapist. In addition, the provider must be licensed or certified
as a mental health provider by the state in which he or she provides services. An eligible mental
health facility must meet all credentialing criteria, including licensure/certification in the state in
which it is operating, and must be approved by the health care option. See the “Eligible Health
Care Professionals” and “Eligible Facilities” sections in this SPD for more information.
Substance Abuse
Eligible providers for substance abuse services are physicians, hospitals and outpatient substance
abuse treatment programs approved by the health care option. See the “Eligible Health Care
Professionals” and “Eligible Facilities” sections in this SPD for more information.
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Retiree Health Care SPD Effective January 1, 2012
What Is Not Covered
The following mental health and substance abuse services are specifically not covered:
• Services to hold or confine a person under chemical influence when no medical services are
required, except as required by law.
• Marriage counseling or training services.
• Interpersonal relationship counseling.
• Treatment of codependency.
• Custodial and supportive care.
• Court-ordered services that are not medically necessary.
• Special education, therapy, counseling or care for learning disorders or behavioral problems
whether or not associated with a manifest mental disorder, mental retardation or other
disturbance.
• Services related to mental illness that are not listed in the most recent edition of the
International Classification of Diseases.
• Biofeedback.
Preventive Care
As required by law, you are not responsible for paying for eligible preventive care services
received from an in-network/participating provider. These eligible preventive care services
will be paid by the plan at 100%, no deductible. Such services include:
• Evidence-based recommended items or services of the United States Preventive Services
Task Force (USPSTF) with a rating of "A" or "B";
• Immunizations recommended from the Advisory Committee on Immunization Practices
(ACIP) of the Centers for Disease Control (CDC); and
• Evidence-informed preventive care and screenings provided for in the comprehensive
guidelines supported by the Health Resources and Services Administration (HRSA) for
infants, children, adolescents and women.
Note: Recommended ages and populations vary for the services listed above. Refer to the charts in
this section for more detailed information about eligible preventive care services. In addition,
eligible preventive care services received from an out-of-network/non-participating provider
will not be covered.
Providers are legally required to code and bill accurately for services they provide to patients.
Covered services are paid based on the billing codes used by your provider on the claim
submitted to BCBS for payment. Therefore, you may be responsible for a portion of the
preventive care visit when:
– the service is not billed as preventive care (including those that may have been received
at the same time as your preventive care visit);
– you do not meet the criteria (based on age or population) for the recommendation or
guideline for the preventive care service; or
– the preventive care service was received from an out-of-network/non-participating
provider.
Please call BCBS if you have questions about coverage. Telephone numbers are listed in the
“Important Resources” section in this SPD.
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Retiree Health Care SPD Effective January 1, 2012
Covered Preventive Services for Men
Service Special Notes
Abdominal Aortic Aneurysm
screening
Alcohol Misuse screening and
counseling
The USPSTF recommends one-time screening for
abdominal aortic aneurysm (AAA) by ultrasonography in
men aged 65 to 75 who have ever smoked.
The USPSTF recommends screening and behavioral
counseling interventions to reduce alcohol misuse by adults,
including pregnant women, in primary care settings.
Blood Pressure screening The USPSTF recommends screening for high blood
pressure in adults aged 18 and older.
Cholesterol screening The USPSTF recommends screening men aged 20 to 35 for
lipid disorders if they are at increased risk for coronary
heart disease. The USPSTF strongly recommends screening
men aged 35 and older for lipid disorders.
Colorectal Cancer screening The USPSTF recommends screening for colorectal cancer
(CRC) using fecal occult blood testing, sigmoidoscopy, or
colonoscopy, in adults, beginning at age 50 years and
continuing until age 75 years. The risks and benefits of
these screening methods vary. Coverage also provided if
proctoscopy is used for this screening.
Depression screening The USPSTF recommends screening adults for depression
when staff-assisted depression care supports are in place to
assure accurate diagnosis, effective treatment, and followup.
Diabetes (Type 2) screening The USPSTF recommends screening for type 2 diabetes in
asymptomatic adults with sustained blood pressure (either
treated or untreated) greater than 135/80 mm Hg.
Diet counseling The USPSTF recommends intensive behavioral dietary
counseling for adult patients with hyperlipidemia and other
known risk factors for cardiovascular and diet-related
chronic disease. Intensive counseling can be delivered by
primary care clinicians or by referral to other specialists,
such as nutritionists or dietitians.
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Retiree Health Care SPD Effective January 1, 2012
Covered Preventive Services for Men, continued
Service Special Notes
Hearing screening Coverage provided for routine hearing screenings.
HIV screening The USPSTF strongly recommends that clinicians screen
for human immunodeficiency virus (HIV) all adolescents
Immunization Vaccines
(Standard)
• Hepatitis A
• Hepatitis B
• Herpes Zoster (Shingles)
• Influenza
• Measles, Mumps, Rubella
• Meningococcal
• Pneumococcal
• Tetanus, Diphtheria,
Pertussis
• Varicella (Chickenpox)
and adults at increased risk for HIV infection.
The ACIP recommendations for doses, recommended ages,
and recommended populations vary. See
www.cdc.gov/vaccines/recs/schedules for detailed
information.
Obesity screening The USPSTF recommends that clinicians screen all adult
patients for obesity and offer intensive counseling and
behavioral interventions to promote sustained weight loss
for obese adults.
Physical Examination Coverage provided for routine physical examinations.
However, there is no coverage for: physicals for research;
obtaining licensure, employment or insurance; or
participation in sports or camp.
Prostate Cancer screening Coverage provided for men 40 years of age or over who are
symptomatic or in a high-risk category and for all men 50
years of age or older. The screening consists of a Prostate
Specific Antigen (PSA) blood test and a Digital Rectal
Sexually Transmitted Infection
(STI) prevention counseling
Examination (DRE).
The USPSTF recommends high-intensity behavioral
counseling to prevent sexually transmitted infections (STIs)
for all sexually active adolescents and for adults at increased
risk for STIs.
Syphilis screening The USPSTF strongly recommends that clinicians screen
persons at increased risk for syphilis infection.
Tobacco Use screening The USPSTF recommends that clinicians ask all adults
about tobacco use and provide tobacco cessation
Vision Exam, Including
Refraction
interventions for those who use tobacco products.
Coverage provided for routine vision exam.
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Retiree Health Care SPD Effective January 1, 2012
Covered Preventive Services for Women, Including Pregnant Women
Service Special Notes
Anemia screening The USPSTF recommends routine screening for iron
Alcohol Misuse screening and
counseling
Bacteriuria Urinary Tract or
Other Infection screening
deficiency anemia in asymptomatic pregnant women.
The USPSTF recommends screening and behavioral
counseling interventions to reduce alcohol misuse by adults,
including pregnant women, in primary care settings.
The USPSTF recommends screening for asymptomatic
bacteriuria with urine culture for pregnant women at 12 to
16 weeks' gestation or at the first prenatal visit, if later.
Blood Pressure screening The USPSTF recommends screening for high blood
pressure in adults aged 18 and older.
Breast Cancer Chemoprevention The USPSTF recommends that clinicians discuss
counseling
chemoprevention with women at high risk for breast cancer
and at low risk for adverse effects of chemoprevention.
Clinicians should inform patients of the potential benefits
and harms of chemoprevention.
Breast Cancer Mammography The USPSTF recommends screening mammography for
screenings
women with or without clinical breast examination (CBE),
every 1-2 years for women aged 40 and older.
Breast Feeding interventions The USPSTF recommends interventions during pregnancy
and after birth to promote and support breastfeeding.
BRCA counseling The USPSTF recommends that women whose family
history is associated with an increased risk for deleterious
mutations in BRCA1 or BRCA2 genes be referred for
genetic counseling and evaluation for BRCA testing.
Cervical Cancer screening The USPSTF strongly recommends screening for cervical
cancer in women who have been sexually active and have a
cervix.
Chlamydia Infection screening The USPSTF recommends screening for chlamydial
infection for all sexually active non-pregnant young women
aged 24 and younger and for older non-pregnant women
who are at increased risk. The USPSTF recommends
screening for chlamydial infection for all pregnant women
aged 24 and younger and for older pregnant women who are
at increased risk.
Cholesterol screening The USPSTF recommends screening women aged 20 to 45
for lipid disorders if they are at increased risk for coronary
heart disease. The USPSTF strongly recommends screening
women aged 45 and older for lipid disorders if they are at
increased risk for coronary heart disease.
Colorectal Cancer screening The USPSTF recommends screening for colorectal cancer
(CRC) using fecal occult blood testing, sigmoidoscopy, or
colonoscopy, in adults, beginning at age 50 years and
continuing until age 75 years. The risks and benefits of these
screening methods vary. Coverage also provided if
proctoscopy is used for this screening.
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Covered Preventive Services for Women, Including Pregnant Women, continued
Service Special Notes
Depression screening The USPSTF recommends screening adults for depression
when staff-assisted depression care supports are in place to
assure accurate diagnosis, effective treatment, and followup.
Diabetes (Type 2) screening The USPSTF recommends screening for type 2 diabetes in
asymptomatic adults with sustained blood pressure (either
treated or untreated) greater than 135/80 mm Hg.
Diet counseling The USPSTF recommends intensive behavioral dietary
counseling for adult patients with hyperlipidemia and other
known risk factors for cardiovascular and diet-related
chronic disease. Intensive counseling can be delivered by
primary care clinicians or by referral to other specialists,
such as nutritionists or dietitians.
Gonorrhea screening The USPSTF recommends that clinicians screen all sexually
active women, including those who are pregnant, for
gonorrhea infection if they are at increased risk for infection
(that is, if they are young or have other individual or
population risk factors).
Gynecological Examination Coverage provided for routine gynecological examinations.
Hearing screening Coverage provided for routine hearing screenings.
Hepatitis B screening The USPSTF strongly recommends screening for hepatitis B
virus (HBV) infection in pregnant women at their first
prenatal visit.
HIV screening The USPSTF strongly recommends that clinicians screen for
human immunodeficiency virus (HIV) all adolescents and
Immunizations Vaccines
(Standard)
• Hepatitis A
• Hepatitis B
• Herpes Zoster (Shingles)
• Human Papillomavirus
• Influenza
• Measles, Mumps, Rubella
• Meningococcal
• Pneumococcal
• Tetanus, Diphtheria,
Pertussis
• Varicella (Chickenpox)
adults at increased risk for HIV infection.
The ACIP recommendations for doses, recommended ages,
and recommended populations vary. See
www.cdc.gov/vaccines/recs/schedules for detailed
information.
Obesity screening The USPSTF recommends that clinicians screen all adult
patients for obesity and offer intensive counseling and
behavioral interventions to promote sustained weight loss
for obese adults.
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Retiree Health Care SPD Effective January 1, 2012
Covered Preventive Services for Women, Including Pregnant Women, continued
Service Special Notes
Osteoporosis The USPSTF recommends that routine screening begin at
age 60 for women at increased risk for osteoporotic
fractures. The USPSTF recommends that women aged 65
and older be screened routinely for osteoporosis.
Ovarian Cancer screening Coverage provided for Cancer Antigen-125 (CA-125) blood
test and transvaginal ultrasound screenings for ovarian
cancer when ordered or provided by a physician in
accordance with the standard practice of medicine.
Physical Examination Coverage provided for routine physical examinations.
However, there is no coverage for: physicals for research;
obtaining licensure, employment or insurance; or
Rh Incompatibility screening and
follow-up testing
Sexually Transmitted Infection
(STI) prevention counseling
participation in sports or camp.
The USPSTF strongly recommends Rh (D) blood typing
and antibody testing for all pregnant women during their
first visit for pregnancy-related care. The USPSTF
recommends repeated Rh (D) antibody testing for all
unsensitized Rh (D)-negative women at 24-28 weeks'
gestation, unless the biological father is known to be Rh
(D)-negative.
The USPSTF recommends high-intensity behavioral
counseling to prevent sexually transmitted infections (STIs)
for all sexually active adolescents and for adults at increased
risk for STIs.
Syphilis screening The USPSTF strongly recommends that clinicians screen
persons at increased risk for syphilis infection. The USPSTF
recommends that clinicians screen all pregnant women for
syphilis infection.
Tobacco Use screening The USPSTF recommends that clinicians ask all adults
about tobacco use and provide tobacco cessation
interventions for those who use tobacco products. The
USPSTF recommends that clinicians ask all pregnant
women about tobacco use and provide augmented,
Vision Exam, Including
Refraction
pregnancy-tailored counseling for those who smoke.
Coverage provided for routine vision exam.
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Retiree Health Care SPD Effective January 1, 2012
Covered Preventive Services for Children
Service Special Notes
Alcohol and Drug Use assessments HRSA recommends alcohol and drug use assessments for
adolescents.
Autism screening HRSA recommends autism screening for children at 18 and
24 months.
Behavioral assessments HRSA recommends behavioral assessments for children of
all ages.
Cervical Dysplasia screening HRSA recommends screening for cervical dysplasia in
females who have been sexually active and have a cervix.
Depression screening The USPSTF recommends screening of adolescents (12-18
years of age) for major depressive disorder (MDD) when
systems are in place to ensure accurate diagnosis,
psychotherapy (cognitive-behavioral or interpersonal), and
follow-up.
Developmental screening HRSA recommends developmental screening for children
under age 3, and surveillance throughout childhood.
Dyslipidemia screening HRSA recommends dyslipidemia screening for children at
Fluoride Chemoprevention
supplements
higher risk of lipid disorders.
The USPSTF recommends that primary care clinicians
administer (or prescribe) oral fluoride supplementation at
currently recommended doses to preschool children older
than 6 months of age whose primary water source is
deficient in fluoride. Coverage is only available when
administered by the physician.
Gonorrhea preventive medication The USPSTF strongly recommends prophylactic ocular
topical medication for all newborns against gonococcal
ophthalmia neonatorum. Coverage is only available when
administered by the physician.
Hearing screening The USPSTF recommends screening for hearing loss in all
newborn infants. Coverage also provided for routine hearing
screenings for children of all ages.
Height, Weight and Body Mass HRSA recommends height, weight and body mass index
Index measurements
measurements for children.
Hematocrit or Hemoglobin HRSA recommends hematocrit or hemoglobin screening for
screening
children.
Hemoglobinopathies screening The USPSTF recommends screening for sickle cell disease
in newborns.
HIV screening The USPSTF strongly recommends that clinicians screen
for human immunodeficiency virus (HIV) all adolescents
and adults at increased risk for HIV infection.
Hypothyroidism screening The USPSTF recommends screening for congenital
hypothyroidism (CH) in newborns.
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Retiree Health Care SPD Effective January 1, 2012
Covered Preventive Services for Children, continued
Service Special Notes
Immunizations Vaccines
(Standard)
• Hepatitis A
• Hepatitis B
• Human Papillomavirus
• Influenza
• Measles, Mumps, Rubella
• Meningococcal
• Pneumococcal
• Rotavirus
• Tetanus, Diphtheria,
Pertussis
• Varicella (Chickenpox)
The ACIP recommendations for doses, recommended ages,
and recommended populations vary. See
www.cdc.gov/vaccines/recs/schedules for detailed
information.
Lead screening HRSA recommends lead screening for children at risk of
exposure.
Medical History HRSA recommends medical history for all children
throughout development.
Obesity screening The USPSTF recommends that clinicians screen children
aged 6 years and older for obesity and offer them or refer
them to comprehensive, intensive behavioral interventions
to promote improvement in weight status.
Oral Health Risk assessment HRSA recommends oral health risk assessment for young
children.
Phenylketonuria (PKU) screening The USPSTF recommends screening for phenylketonuria
Physical (Well Child Care)
Examination
Sexually Transmitted Infection
(STI) prevention counseling
(PKU) in newborns.
Coverage provided for routine physical (well child care)
examinations. However, there is no coverage for: physicals
for research; obtaining licensure, employment or insurance;
or participation in sports or camp.
The USPSTF recommends high-intensity behavioral
counseling to prevent sexually transmitted infections (STIs)
for all sexually active adolescents and for adults at
increased risk for STIs.
Tuberculin testing HRSA recommends tuberculin testing for children at higher
risk of tuberculosis.
Visual Acuity screening The USPSTF recommends screening to detect amblyopia,
strabismus, and defects in visual acuity in children younger
Vision Exam, Including
Refraction
than age 5 years.
Coverage provided for routine vision exam.
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Retiree Health Care SPD Effective January 1, 2012
Spine Surgery
In order to receive the highest level of benefits, use of a Blue Distinction Centers for Spine
Surgery SM is required for members age 18 and older for health care plans administered by BCBS.
This national network includes facilities that have demonstrated their commitment to quality
care, resulting in better overall outcomes for spine surgery patients. Blue Distinction Centers
for Spine Surgery SM provide comprehensive inpatient spine surgery services, including
discectomy, fusion and decompression procedures.
You may view a listing of designated centers at www.bluecrossmn.com/usb. Once you locate a
designated center, you need to confirm the designated center is participating in your applicable
network. To do this, choose your applicable network from the drop down menu under “Network”
and search for the designated center to make sure it displays. You may also get information by
calling BCBS customer service (see the “Important Resources” section in this SPD).
Expenses for Travel and Lodging
Expenses for travel and lodging for the patient and a companion are available as follows:
• Transportation of the patient and one companion who is traveling on the same day(s) to
and/or from the site of the surgery for the purposes of an evaluation, the surgical procedure
or necessary post-discharge follow-up.
• Reasonable and necessary expenses for lodging for the patient (while not hospitalized) and
lodging only for one companion. Expenses are reimbursed at a per diem rate of up to $50 for
one person or up to $100 for two people.
• Travel and lodging expenses are available only if the patient resides more than 50 miles from
the designated facility.
There is a combined overall lifetime maximum of $1,500 paid by the Program per covered
person for all transportation and lodging expenses incurred by the patient and companion(s) and
reimbursed under this Program in connection with the surgery. Note: The deductible must be met
by members enrolled in the Early Retiree Medical option before these expenses can be
reimbursed by the Program.
The Women’s Health and Cancer Rights Act of 1998
The Women’s Health and Cancer Rights Act requires that group health plans providing coverage
for mastectomies also provide certain mastectomy-related benefits or services. Under federal
law, because this Program provides medical and surgical benefits for mastectomies, it must also
provide coverage for:
• reconstruction of the breast on which the mastectomy was performed;
• surgery and reconstruction on the other breast to produce a symmetrical appearance; and
• coverage for prostheses and physical complications at all stages of the mastectomy, including
lymphedemas.
The same deductibles and coinsurance limitations apply to these procedures as apply to any other
illness.
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Retiree Health Care SPD Effective January 1, 2012
Transplants
Coverage for transplants is limited to human organ or tissue transplants that are not
experimental, investigative or unproven, including bone marrow, kidney, cornea, heart, lung(s),
or heart and lung(s), liver, and pancreas if in conjunction with a kidney transplant. There is no
coverage for artificial organs, transplantation of animal organs and/or tissue, and all services and
supplies related to artificial or non-human organ implants. Contact BCBS for information about
living donor transplant coverage.
All transplants must be performed at a participating transplant center associated with BCBS.
Services performed at non-participating transplant centers are not covered even if the
services are medically necessary and/or referred. Other benefit limits and restrictions
apply.
All transplants, except cornea and kidney transplants, must be received at a Blue Distinction
Centers for Transplants ® . A BCBS Transplant Coordinator will authorize and coordinate your
care and assist you with travel and lodging reimbursement. Contact a BCBS Transplant
Coordinator at 651-662-9936 or 866-309-6564. You may view a listing of designated transplant
centers at www.bluecrossmn.com/usb.
Expenses for Travel and Lodging
Except for cornea and kidney transplants, expenses for travel and lodging for the transplant
recipient and a companion are available as follows:
• Transportation of the patient and one companion who is traveling on the same day(s) to
and/or from the site of the transplant for the purposes of an evaluation, the transplant
procedure or necessary post-discharge follow-up.
• Reasonable and necessary expenses for lodging for the patient (while not hospitalized) and
lodging only for one companion. Expenses are reimbursed at a per diem rate of up to $50 for
one person or up to $100 for two people.
• Travel and lodging expenses are available only if the transplant recipient resides more than
50 miles from the designated transplant facility.
• If the patient is a covered dependent minor child, the transportation expenses of two
companions will be covered and lodging expenses will be reimbursed up to the $100 per
diem rate.
There is a combined overall lifetime maximum of $10,000 paid by the plan per covered person
for all transportation and lodging expenses incurred by the transplant recipient and companion(s)
and reimbursed under this plan in connection with the transplant. Note: The deductible must be
met by members enrolled in the Early Retiree Medical option before these expenses can be
reimbursed by the Program.
Non-Custodial and Full-Time Student Dependents Under the Early Retiree
Medical Option
If you are required by law to maintain health care coverage for a dependent (under age 18) who
lives outside your state or network service area or if you have an eligible dependent attending
school full-time outside your state or network service area, your dependent may choose an
eligible BCBS BlueCard PPO network provider in the location where your dependent resides.
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Retiree Health Care SPD Effective January 1, 2012
The eligible claims are processed at the in-network (rather than out-of network) benefits level
when your dependent receives care from an eligible BCBS BlueCard PPO network provider in
his/her location. You may find BCBS BlueCard PPO providers on the BCBS of MN Web site or
call BCBS at 1-800-810-BLUE (1-800-810-2583) during regular business hours for a list of
participating providers in your dependent's area.
Filing Health Care Claims - BCBS
You do not file claims when you use in-network or participating providers. However, you
are responsible for paying any applicable deductibles, copayments or coinsurance directly to the
provider either at the time of your visit or when your provider sends you a bill for these amounts.
If you receive services from an out-of-network or non-participating provider: You may
need to pay that provider in full and then file a claim with BCBS for reimbursement. Claim
forms are available online on the BCBS of MN Web site or you can request the form by calling
the BCBS of MN customer service department (see the “Important Resources” section in this
SPD). Claims must be submitted to BCBS within 12 months from the date of service.
For BCBS claims, you need to include your complete member ID number on the claim form.
This includes the alpha prefix (e.g., FBO, UBI, etc.) on your ID card.
For information on filing pharmacy claims, see the “Filing Pharmacy Claims – Medco” section
in this SPD.
Allowed Amounts
To make sure the fees charged by providers are not excessive, the Early Retiree Medical and
Comprehensive options pay based on “allowed amounts." The allowed amount is the negotiated
amount of payment that a participating provider has agreed to accept as payment in full (less
deductibles, coinsurance and copayments) for covered services at the time a claim is processed.
All Program payments are based on the allowed amount. The allowed amount may vary from
one provider to another for the same service. Also, BCBS may periodically adjust the allowed
amount.
If participating providers charge more than the allowed amount, the difference will appear in the
provider reduction column on your Explanation of Benefits (the statement sent from BCBS
following a claim). Except for non-covered services, you should not be billed for any amounts
exceeding allowed amounts when you use participating providers. Refer to the “Which Network
Providers to Use” section in this SPD for more information. If you are so billed, do not pay the
invoice. Check with your health care provider or call the BCBS customer service department.
For BCBS-administered options: When you obtain health care services through the BlueCard
Program outside the geographic area BCBS of MN serves, the amount you pay for covered
services is usually calculated on the lower of:
1. The billed charges for your covered services; or
2. The negotiated price that the on-site Blue Cross and/or Blue Shield Plan (“Host Blue”) passes
on to BCBS of MN.
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Retiree Health Care SPD Effective January 1, 2012
Often, this “negotiated price” consists of a simple discount that reflects the actual price paid by
the Host Blue. Sometimes, however, the negotiated price is either 1) an estimated price that
factors expected settlements, withholds, any other contingent payment arrangements and nonclaims
transactions with your health care provider or with a specified group of providers into the
actual price; or 2) billed charges reduced to reflect an average expected savings with your health
care provider or with a specified group of providers. The price that reflects average savings may
result in greater variation (more or less) from the actual price paid than will the estimated price.
The negotiated price will be prospectively adjusted to correct for over- or underestimation of past
prices. The amount you pay, however, is considered a final price and will not be affected by the
prospective adjustment.
Statutes in a small number of states may require the Host Blue either 1) to use a basis for
calculating your liability for covered services that does not reflect the entire savings realized or
expected to be realized on a particular claim; or 2) to add a surcharge. If any state statutes
mandate liability calculation methods that differ from the usual BlueCard method noted above or
require a surcharge, BCBS of MN will calculate your liability for any covered health care
services according to the applicable state statute in effect at the time you received your care.
Regardless of the option you are enrolled in, if you obtain care from a non-participating
provider, you are responsible for paying the difference between the billed charge and the
allowed amount if your provider charges more than the allowed amount. The additional
cost would depend on what your physician charges. For expensive procedures, this amount
could be significant. Also, this excess amount will not apply to deductibles or out-of-pocket
maximums.
For BCBS participants using a non-participating provider, if the provider is:
• a facility in Minnesota, the allowed amount is a designated percentage of the facility’s billed
charges. Outside of Minnesota, the allowed amount is determined by the local Blue Cross
and/or Blue Shield Plan, unless that amount is greater than the billed charge, or no allowed
amount is provided by the local Blue Plan. In that case, the allowed amount is determined
from a Medicare-based fee schedule. If such pricing is not available, payment will be based
on a percentage of the billed charges.
• a physician or clinic in Minnesota, the allowed amount is the lesser of: (1) the
Nonparticipating Provider Professional Services in Minnesota Fee Schedule or (2) a
designated percentage of the billed charges. Outside of Minnesota, the allowed amount is
determined by the local Blue Cross and/or Blue Shield Plan, unless that amount is greater
than the billed charge, or no allowed amount is provided by the local Blue Plan. In that case,
the allowed amount payment will be based on a percentage of pricing obtained from a
nationwide provider reimbursement database that considers various factors, including the zip
code of the place of service and the type of service provided. If this database pricing is not
available for the service provided, payment will be based on the lesser of: (1) the
Nonparticipating Provider Professional Services in Minnesota Fee Schedule or (2) a
designated percentage of the billed charges.
When you receive care from certain non-participating professionals, the reimbursement to the
non-participating professional may include some of the costs that you would otherwise be
required to pay (e.g., the difference between the allowed amount and the provider's billed charge)
as well as the services may be paid at the highest level of benefits. This applies in limited
circumstances when you receive care from non-participating professionals and you did not have
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Retiree Health Care SPD Effective January 1, 2012
the opportunity to select the provider. Examples of this situation include diagnostic lab,
independent diagnostic X-ray and independent anesthesia providers.
To locate in-network/participating providers, you may ask your provider if he or she participates
with BCBS, call the BCBS customer service department, or access their Web site*. (See the
“Important Resources” section of this SPD.) In addition, you may call 1-800-810-BLUE (1-800-
810-2583).
It is your responsibility to confirm that the provider you use is an in-network/participating
provider.
* Every effort is made to ensure that the list of providers on the BCBS Web site is up-to-date and accurate.
However, the network is subject to change throughout the year. It is your responsibility to verify that the provider
you or a covered family member uses is in the network associated with your health care option. You should call
BCBS’s customer service department or access their Web site before you receive care to find out if a specific
provider continues to be part of the network.
Example
The following example (if you are enrolled in the Comprehensive option) shows how coverage is
calculated when you use a non-participating or participating provider, assuming your annual
deductible has already been satisfied. In the example, the physician's charges exceed the
Program's allowed amount.
Out-of-Network In-Network
Billed charge for covered service: $100 Billed charge for covered service: $100
Allowed amount: $85 Allowed amount: $85
Non-participating coverage pays 60% $51 Participating coverage pays 80% of $68
of $85:
$85:
You pay $100 minus $51: $49 You pay $85 minus $68: $17
Eligible Health Care Professionals
In order to receive coverage for eligible health care expenses, you need to make sure the
practitioner you are using is eligible. To be eligible, practitioners must practice within the scope
of their licenses and must not be members of your immediate family. Examples of eligible
practitioners include:
• Doctors of medicine (MD) and their supervised employees
• Doctors of chiropractic (DC) and their supervised employees
• Doctors of podiatry (DP or DPM)
• Doctors of optometry (OD)
• Doctors of osteopathy (DO)
• Optometrists
• Licensed acupuncture practitioner
• Licensed psychologists
• Licensed consulting psychologists (LCP)
• Doctors of dental surgery (DDS)
• Certified nurse midwives
• Nurse anesthetists
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Retiree Health Care SPD Effective January 1, 2012
• Nurse practitioners
• Audiologists
• Physical therapists (PT)
• Certified speech and language pathologists
• Occupational therapists (OT)
• Master level clinical social workers (MLCSW)
• Licensed professional counselors
• Mental health professionals
• Physician assistants
• Registered dieticians
Note: Although a practitioner may be considered eligible, services provided by the practitioner
may not be eligible under your option. Please see the “What the Options Cover” and the
“General Exclusions” sections in this SPD. In addition, there may be other types of practitioners
that are eligible, but not listed. If you have any questions regarding eligible practitioners, call the
BCBS customer service department at the number listed in the “Important Resources” section in
this SPD.
Home Health Care
Covered home health care services must be provided by an eligible provider, examples of which
include:
• Nurse
• Physical therapist (PT)
• Certified speech and language pathologist
• Medical technologist
• Dietician
• Master level clinical social worker (MLCSW)
• Occupational therapist (OT)
• Home health aide
Note: Although a provider may be considered eligible, services provided by the provider may
not be eligible under your plan. Please see the “What the Options Cover” and the “General
Exclusions” sections in this SPD. In addition, there may be other types of providers that are
eligible, but not listed. If you have any questions regarding eligible providers, call the BCBS
customer service department at the number listed in the “Important Resources” section in this
SPD.
Eligible Facilities
In order to receive coverage for eligible health care expenses, you need to make sure the facility
you are using is eligible. For example, hospitals providing care must generally be licensed, under
the direction of physicians, have 24-hour registered nursing services, and be privately owned, or
owned or operated by state or local government to be eligible. Examples of eligible facilities are:
• Hospitals
• Skilled nursing facilities
• Residential treatment facilities for substance abuse and mental health
• Hospices
• Ambulatory surgery centers
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Retiree Health Care SPD Effective January 1, 2012
• Outpatient mental health facilities
• Outpatient substance abuse facilities
Note: Although a facility may be considered eligible, services provided by the facility may not
be eligible under your option. Please see the “What the Options Cover” and the “General
Exclusions” sections in this SPD. In addition, there may be other types of facilities that are
eligible, but not listed. If you have any questions regarding eligible facilities, call the BCBS
customer service department at the number listed in the “Important Resources” section in this
SPD. Examples of facilities not eligible under the Program are retirement homes, nursing homes,
spas and health clubs.
General Exclusions
Although the U.S. Bank Retiree Health Care Program options cover most medically necessary
services, there are some expenses that are not covered. Some of the services not covered are
listed in the coverage charts and in the “Mental Health and Substance Abuse Coverage” section
in this SPD. BCBS has the discretion to determine whether a service/procedure is medically
necessary. If you have a question about whether an expense is covered, please call BCBS.
The following services are specifically not covered:
1. Any treatment, service or supply that is not medically necessary. (See “Medically Necessary”
in the “Glossary of Terms” section in this SPD for more detailed information.)
2. Any treatment, service or supply that is not generally accepted and usual for the treatment of
an illness, in accordance with the terms of the U.S. Bank plan document and the BCBS
medical staff.
3. Preventive care or any treatment, service or supply that is educational, developmental,
experimental, investigative or unproven in nature. This includes health services that are
considered experimental or investigative, performed for the purpose of research, or unproven
procedures, in accordance with the terms of the U.S. Bank plan document and the BCBS
medical staff. (See “Experimental, Investigative or Unproven” in the section “Glossary of
Terms” in this SPD for a more detailed definition.)
4. Health services eligible for payment under any workers' compensation or employer's liability
law or similar law or act, or covered under any no-fault insurance policy to the extent that the
no-fault policy covers services eligible under this Program, or any expenses that would
otherwise be the responsibility of a third party. (See the section “When You Have Other
Coverage – BCBS” in this SPD.)
5. The portion of eligible services and supplies paid or payable under Medicare. (See the
section “When You Have Other Coverage – BCBS” in this SPD.)
6. Charges that are eligible, paid or payable, under any medical payment, personal injury
protection, automobile or other coverage that is payable without regard to fault, including
charges that are applied toward any deductible, copayment or coinsurance requirement of
such a policy.
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7. Services for or related to treatment of illness or injury which occurs while on military duty
and that are recognized by the Veteran's Administration as services related to serviceconnected
injuries.
8. Health services needed because the patient committed or attempted to commit a felony, or
engaged in an illegal occupation.
9. Services that are prohibited by law or regulation.
10. Examinations or treatment ordered by a court in connection with legal proceedings unless
such examinations or treatment is otherwise covered under the terms of this Program.
11. Services or confinements ordered by a court or law enforcement officer that are not
medically necessary. Services that are not considered medically necessary include, but are
not limited to the following: custody evaluation, parenting assessment, education classes for
DUI offenses, competency evaluations, adoption home status, parental competency and
domestic violence programs.
12. Court-ordered mental health services unless otherwise specified as covered under the
Program. (Refer to the “Mental Health and Substance Abuse Coverage” section in this SPD.)
13. Services received before you or your dependents are covered under the Program.
14. Services received after you or your dependent loses coverage under the Program.
15. Services received by your dependent if your dependent is a U.S. Bank employee with his/her
own coverage.
16. Expenses incurred after the Program or plan terminates, except when the patient was
confined in a hospital on the date of termination. The Program would be responsible for
eligible charges until the patient was discharged.
17. Services, supplies, medical care or treatment given by you or by your or your spouse's
immediate family, spouse, child, brother, sister, parent or grandparent.
18. Services given by volunteers or persons who do not normally charge for their services.
19. Services given by a pastoral counselor.
20. Services that are not within the scope, licensure, or certification of a provider.
21. Telephone consultation.
22. Charges for failure to keep scheduled visits.
23. Charges for furnishing medical records or reports.
24. Charges for the completion of claim forms.
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Retiree Health Care SPD Effective January 1, 2012
25. Charges in excess of the allowed amount.
26. Charges for non-notification penalties.
27. Services and supplies that the participant is not legally required to pay.
28. Travel, transportation, or living expenses, whether or not recommended by a physician,
unless they are deemed eligible as part of the bariatric surgery, knee and hip replacements,
spine surgery or transplant benefit.
29. Services for or related to transportation other than local ambulance service to the nearest
medical facility equipped to treat the illness or injury, except as specified in the benefit charts
in this SPD.
30. Services or supplies that are primarily and customarily used for non-medical purpose, or used
for environmental control or enhancement (whether or not prescribed by a physician),
including, but not limited to: exercise equipment, air purifiers, air conditioners, hot tubs,
whirlpools, dehumidifiers, heat/cold appliances, water purifiers, hypoallergenic mattresses,
waterbeds, vehicle lifts, computers and related equipment, car seats, feeding chairs, pillows,
food or weight scales, and incontinence pads or pants.
31. Modifications to home, vehicle and/or workplace, including home, work or vehicle lifts and
ramps.
32. Personal comfort or convenience items, including, but not limited to, telephone, television,
barber and beauty supplies and guest services.
33. Blood pressure monitoring devices.
34. Breast pumps.
35. Communication devices, except when exclusively used for the communication of daily
medical needs and without such communication, the patient’s medical condition would
deteriorate.
36. Nursing services to administer home infusion therapy when the patient or caregiver can be
successfully trained to administer therapy. Services that do not involve direct patient contact,
such as delivery charges and record-keeping.
37. Charges for or related to care that is custodial, or not normally provided as preventive care or
treatment of an illness.
38. Charges for or related to private-duty nursing.
39. Charges for rehabilitation services that would not result in measurable progress relative to
established goals.
40. Charges for or related to recreational or educational therapy, or forms of non-medical self
care or self-help training, including, but not limited to: health club memberships, aerobic
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Retiree Health Care SPD Effective January 1, 2012
conditioning, therapeutic exercises, massage therapy, work hardening programs, etc., and all
related materials and products for these programs.
41. Services, chemotherapy, radiation therapy (or any therapy that results in marked or complete
suppression of blood producing organs), supplies, drugs and aftercare for or related to bone
marrow and peripheral stem cell support procedures, except as specified in the benefit charts
in this SPD.
42. Treatment, equipment, drug and/or device that the medical Claims Administrator determines
does not meet generally accepted standards of practice in the medical community for cancer
and/or allergy testing and/or treatment. Services for or related to chelation therapy that BCBS
determines is not medically necessary. Services for or related to systemic candidiasis,
homeopathy and/or immunoaugmentative therapy.
43. Services for or related to growth hormone, except that replacement therapy is eligible for
conditions that meet medical necessity criteria as determined by BCBS prior to receiving
services.
44. Services for or related to gene therapy as a treatment for inherited or acquired disorders,
except as specified in the benefit charts in this SPD.
45. Services for or related to therapeutic acupuncture, except for the treatment of chronic pain
when treatment is provided through a comprehensive pain management program or for the
prevention and treatment of nausea associated with surgery, chemotherapy or pregnancy as
specified in the benefit charts in this SPD.
46. Services for or related to smoking cessation program fees and/or related program supplies.
47. Services for or related to hearing aids or devices, whether internal, external or implantable,
and related fitting or adjustments, except as specified in the benefit charts in this SPD.
48. Services for or related to fetal tissue transplantation.
49. Services for or related to the preservation and storage of human tissue including, but not
limited to: sperm, ova embryos, stem cells, cord blood and any other human tissue, except as
specified in the benefit charts in this SPD.
50. Services, supplies, drugs and aftercare for or related to artificial or non-human organ
implants.
51. Biofeedback.
52. Autopsies.
53. Services for or related to functional capacity evaluations for vocational purposes and/or
determination of disability or pension benefits.
54. Services for or related to routine physical exams for purposes of medical research, obtaining
employment or insurance, or obtaining or maintaining a license of any type, unless such
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Retiree Health Care SPD Effective January 1, 2012
physical examination would normally have been provided in the absence of the third party
request.
55. Admission for diagnostic tests that can be performed on an outpatient basis unless medically
necessary.
56. Inpatient hospital room and board expenses that exceeds the semi-private room rate, unless a
private room is approved by BCBS as medically necessary.
57. Services for or related to cosmetic health services or reconstructive surgery and related
services and treatment for conditions or problems related to cosmetic surgery or services,
except as specified in the benefit charts in this SPD.
58. Membership costs for health clubs, weight loss clinics and similar programs.
59. Services for or related to commercial weight loss programs, fees or dues, nutritional
supplements, food, vitamins and exercise therapy, and all associated labs, physician visits,
and services related to such programs.
60. Nutritional counseling, except as specified in the benefit charts in this SPD.
61. Charges for or relating to refractive eye surgery when the only goal is to minimize or
eliminate dependence on glasses or contact lenses in otherwise non-diseased corneas,
including laser surgery to correct myopia (nearsightedness), myopic astigmatism, and/or
hyperopia (farsightedness).
62. Services for or related to lenses, frames, contact lenses, and other fabricated optical devices
or professional services for the fitting and/or supply thereof, including the treatment of
refractive errors such as radial keratotomy, except as specified in the benefit charts in this
SPD.
63. Dentures and dental implants, regardless of the cause or condition, and any associated
services and/or charges including bone grafts, except as specified in the benefit charts in this
SPD.
64. Bone grafts for the sole purpose of supporting a dental implant, except as specified in the
benefit charts in this SPD.
65. Services for or related to dental or oral care, implants, treatment, orthodontia, surgery and
any related supplies, anesthesia and facility charges, except as specified in the benefit charts
in this SPD.
66. Services for or related to reversal of sterilization.
67. Services for or related to sex transformation/gender reassignment surgery, sex hormones
related to the surgery, related preparation and follow-up treatment, or care and counseling.
68. Charges for giving injections that can be self-administered.
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Retiree Health Care SPD Effective January 1, 2012
69. Drugs identified as not covered in the “Pharmacy” section in this SPD.
70. All services, treatments, devices or supplies identifiable as being provided in conjunction
with a benefit or service that is not covered.
71. Medical treatment or services identified as not covered in the benefit charts in this SPD.
This is not intended to be an exhaustive list. If you have a question on what your option will
cover, call the BCBS customer service department at the number listed in the “Important
Resources” section in this SPD.
Using Your ID Card When Traveling
Note: This section does not apply to the Kaiser Colorado option or the Medica or
UnitedHealthcare Plan options. If you are enrolled in the Kaiser option or Medica or
UnitedHealthcare option, you should refer to the materials provided to you by Kaiser, Medica
or UnitedHealthcare to determine the provisions and requirements of these benefit options.
If you are traveling, whether within the United States or internationally, do not forget to carry
your medical plan ID card. When you receive care from a BCBS BlueCard PPO or
“participating” provider within the United States, your claims will automatically be submitted to
BCBS for you, and you generally will not be responsible for any dollars the physician charges in
excess of the Program's allowed amounts. In a few locations, however, you are responsible for
the difference between the allowed amount and the amount charged, if greater. In addition,
consistent with state law, in a small number of states, BCBS uses a basis for calculating your
payment for covered services that does not reflect the entire discount realized or expected to be
realized on a particular claim. When you receive covered health services in those states, the
amount you are required to pay will be calculated using these methods.
The benefits you receive will depend on the option you have, the provider you use and the
service you receive. It is recommended that you contact BCBS for specific information before
you travel.
It is important that you show your ID card to the provider at the time you receive services
because the suitcase logo pictured on the front of the ID card allows you the same level of
benefit as those received within your home state. You can also use your medical ID card when
you receive health care services with participating providers in many countries outside the
United States. This is called BlueCard Worldwide ® . Details on BlueCard Worldwide ® can be
found online or by calling customer service (see the “Important Resources” section in this SPD).
Address Changes
If You Spend Time in Another Part of the Country
If you spend time in another part of the country, it is important that you contact the U.S. Bank
Employee Service Center at 1-800-806-7009. You can have two addresses on file at the
Employee Service Center, a permanent address and an alternate address. You will need to
designate which address you want to be your mailing address. Designating the appropriate
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address as your mailing address will ensure you receive all retiree health care mailings. For
example:
John’s permanent address is Minnesota. John doesn’t like Minnesota winters so from December
to April, he lives in Arizona. Just before John leaves for Arizona (his alternate address), he
contacts the U.S. Bank Employee Service Center and designates his Arizona address as his
mailing address. Just before John returns to Minnesota, he contacts the U.S. Bank Employee
Service Center and designates his Minnesota address as his mailing address. By doing this, John
is sure to receive all mailings regarding his retiree health care.
If you are enrolled in the UnitedHealthcare, Medica or Kaiser option, you will also need to refer
to the materials provided to you by UnitedHealthcare, Medica or Kaiser to determine the
provisions and requirements of these benefit options while traveling.
It is important to remember not to change your alternate address to your permanent address. If
you do change your alternate address to your permanent address, your health care option may
change. If you are enrolled in the Kaiser option and that option is not available to you in your
new location, you will have to enroll in the option available in your new location. Once you
have changed coverage from Kaiser to another option, you will not be allowed to re-enroll
in the Kaiser option, even if you change your permanent address back to the Kaiser
network area.
Please note: This process does not apply to a covered dependent that may spend part of the year
away at school. Refer to the “Non-Custodial and Full-Time Student Dependents Under the Early
Retiree Medical Option” section in this SPD.
If Your Address Changes
It is important that you call the U.S. Bank Employee Service Center to report any change of
address as soon as possible. You may update your address by calling the U.S. Bank Employee
Service Center at 1-800-806-7009 and asking a representative to update your address.
Some address changes may result in a change to your Retiree Health Care Program option. In
that event, the process is different depending on the option that you are enrolled in. Please refer
to the following to determine how the process will work for you:
• In you are enrolled in the Early Retiree Medical option and there is no longer a BCBS
network available in your area, you will automatically be placed in the Comprehensive
option. If you are enrolled in the Comprehensive option and there is a now a BCBS
network available in your area you will be automatically place in the Early Retiree
Medical option. The U.S. Bank Employee Service Center will send you a letter
confirming this change. You can obtain information about providers in your new location
by visiting the BCBS Web site or by calling their phone number.
• If you are enrolled in the Medica or UnitedHealthcare Plan option, and your current
option is not available at your new location, the U.S. Bank Employee Service Center will
send you an enrollment kit to enroll in the option that is available in your area. It is
critical that you complete the enrollment application into your new option and
return it the U.S. Bank Employee Service Center right away, to avoid a lapse in
coverage. To obtain information about providers in your new location contact your new
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UnitedHealthcare or Medica Plan option. See the “Important Resources” section of this
SPD for contact information.
• If you are enrolled in the Kaiser Colorado option and it is not offered in your new area,
and you are pre-65 and not Medicare eligible you will automatically be enrolled into
either the Early Retiree Medical option or the Comprehensive option (depending on
whether there is a network available in your area or not). If you are age 65 or older or
Medicare eligible you will need to enroll in the UnitedHealthcare or Medica Plan option
available in your area. See the “Your Health Care Options – Retirees Age 65 or Older or
Pre-65 and Medicare Eligible” section in this SPD for more information.
Even if you know that the same health care option is available in your new location, the address
for submitting claims may not be – so you should report an address change to be sure that your
claims are processed appropriately. If you do not change your address, you may receive the outof-network
level of benefits (which for some services is no coverage) unless your situation is
deemed an emergency.
Network Providers
If you are enrolled in the Early Retiree Medical or Comprehensive option, you may access
eligible providers on the BCBS Web site or by calling their customer service department (see the
“Important Resources” section of this SPD).
Identification Cards
For all options, you can expect to receive new ID cards sent directly to your home address from
your new medical Claims Administrator within two to four weeks following your enrollment.
You must present the applicable ID card when receiving services, so your claim will be handled
promptly. If you do not, you may need to pay for services yourself and file a claim for
reimbursement. Additional or replacement cards can be obtained by contacting the applicable
Claims Administrator.
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FILING CLAIM DISPUTES
This section describes the claim-and-review procedures for all the health care options (except the
Kaiser, Medica and UnitedHealthcare plan options.) These claims and appeals procedures are
effective January 1, 2012.* U.S. Bank has delegated authority and discretion to decide internal
claims and appeals relating to ERISA claims for benefits to the Claims Administrators
responsible for the benefit in question.
If you are enrolled in the Kaiser Colorado option or the Medica or UnitedHealthcare plan
options, you will receive separate materials from that Claims Administrator explaining the claimand-review
procedures for your option. You must follow the claim-and-review procedures
contained in the separate materials in order to ensure the highest level of benefits. Each Kaiser,
Medica and UnitedHealthcare plan is fully insured. Each insurer has the sole authority, discretion
and responsibility to interpret and construe the terms of the benefit plan it insures, and determine
all factual and legal questions under such benefit plan, including but not limited to eligibility to
participate, the entitlement of benefits and the amount of benefits to be paid, if any. U.S. Bank
has no authority to make determinations with respect to any Kaiser, Medica or UnitedHealthcare
plan. Your only source of recovery is from the applicable insurer.
* These procedures include provisions provided by federal health reform law, regulation and subregulatory
guidance. Some of these provisions may be eliminated or changed in subsequent guidance, and to the extent this
occurs, the Plan will be administered in accordance with such eliminations or changes. The Plan reserves the right to
delay compliance to the latest date permitted under current or future regulations.
Eligibility and Enrollment Claims for All Options
All claims or disputes regarding eligibility and enrollment must be submitted in writing to:
U.S. Bank Benefit Claim Subcommittee
EP-MN-R2BN
4000 West Broadway
Robbinsdale, MN 55422-2299
Fax 763-971-1285
Within 60 days after your claim is received, you will receive a written notice of the decision. If
your claim is denied, in whole or in part, the Claim Reviewer will further notify you of your right
to additional review of your denied claim.
If your request for review is denied in whole or in part and you still disagree with the decision,
within 60 days of the date you receive written notice, you must deliver to the U.S. Bank Benefit
Claim Subcommittee a written request for a final claims determination at the above address.
Your request for a final claims determination should include any documentation supporting your
claim.
Release of Medical Records and Medical Reviews
Generally, your health or pharmacy information may be used without obtaining your
authorization or consent for purposes of claims payment and other health care or pharmacy
operations required by the Program. However, in some circumstances, an authorization for the
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release of medical records may be required. If this is required, you may be asked to sign an
authorization permitting the disclosure of your medical records for this purpose.
Internal ERISA Claims Procedures
Initial Claim Determination
Under ERISA’s claims procedures there are three types of claims:
• Post-Service Claims – any claim for payment filed after medical services or supplies
have been received and any other claim that is neither a Pre-Service nor an Urgent Claim.
• Pre-Service Claims – any claim for a benefit that, under the terms of the Program,
requires notification or approval prior to receiving medical treatment or supplies (e.g.,
prior authorization or preadmission notification); and
• Urgent Claims – a Pre-Service claim (as defined above), where, in the opinion of the
claimant's health care provider, a delay in providing medical treatment or supplies might
jeopardize the life or health of the claimant, or jeopardize the ability to regain maximum
function or subject the claimant to severe pain that cannot be adequately managed
without the care or treatment that is the subject of the claim.
The time period for deciding each type of claim and notifying you of such decision differs based
upon the nature of claim. The chart in this section provides the time periods for notifying you of
the initial claims decision, any possible extensions and the time periods for you to provide
additional information, if needed.
Within the timeframes indicated in the chart, you will receive either a:
• Written notice of the decision; or
• For Post-Service Claims, notice describing the need for additional time to reach a
decision due to reasons beyond the control of the Claims Administrator;
• For Pre-Service Claims, notice that your claim was incorrectly filed and information
about how to correctly file a claim or notice describing the need for additional time to
reach a decision due to reasons beyond the control of the Claims Administrator; or
• For Urgent Claims, notice that the claim is incomplete.
If additional time is needed, the notice will describe the reason(s) for the extension and the date
by which you can expect a decision.
If the claim is incomplete or additional information is needed, the notice will specifically
describe the additional information needed to complete the claim. You will then have the time
period indicated in the fourth column of the chart to provide the specified additional information.
The time between the date the notice is sent and the date the requested information is received
from you shall not count against the time period for deciding your claim.
If you fail to follow the procedures for submitting a Pre-Service claim, you will be notified of the
correct process for submitting a Pre-Service claim within five days after the incorrect claim is
received. This notice may be provided orally, unless you request written notification.
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Type of Claim
Post-Service
Claims
Pre-Service
Claims
Urgent Claims
Deadline for Notifying
Claimant of Initial Claim
Determination
30 days after receipt of the
initial claim
15 days after receipt of the
initial claim
INCORRECTLY FILED
CLAIMS
5 days from the date the
incorrect claim was received
by a person regularly
responsible for handling
claims
No later than 72 hours after
receipt of initial claim,
taking into account the
medical urgency
Extensions to Deadline for
Notifying Claimant of
Initial Claim
Determination
15-day extension available
15-day extension available
COMPLETE CLAIMS
NOT APPLICABLE
INCOMPLETE CLAIMS
48 hours after earlier of:
• the date claimant
provides requested
information; or
• the end of 48 hour
period for claimant to
provide requested
information
Time Period, if any, for
Claimant to Provide
Additional Information
60 days after claimant
receives notice of need for
additional information
60 days after claimant
receives notice of need for
additional information
48 hours from the time
claimant receives notice of
an incomplete claim
If your claim is denied, in whole or in part, you will receive a written notice, which includes:
• information about your claim and the reason(s) for the denial;
• the plan or Program provisions on which the denial is based;
• a description of additional material (if any) needed to perfect the claim;
• an explanation of your right to request a review;
• a statement of your right to file a civil action under section 502(a) of ERISA if your claim
is denied upon a request for review;
• a statement indicating whether an internal rule, guideline, protocol or other similar
criterion was relied on in deciding your claim and information explaining your right to
request such information, free of charge;
• if an adverse benefit determination is based on medical necessity or experimental
treatment or a similar exclusion or limitation, an explanation of the scientific or clinical
judgment for the determination applied to the your medical circumstances;
• for Urgent Claims only, a description of the expedited review process applicable to such
claims;
• description of the plan’s standard, if any, used in denying the claim (e.g., if a medical
necessity standard is used to deny the claim, the notice must describe the medical
necessity standard);
• description of available internal appeals and external review processes; and
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• disclosure of availability of and contact information for any applicable office or health
insurance consumer assistance or ombudsman, if any, established by the Department of
Health and Human Services to assist in internal claims, appeals and external review
process.
For Pre-Service and Urgent Claims only, you will receive notice for approved claims as well as
denied claims.
If Your Claim is Denied
If a claim for benefits is denied in whole or in part, you may call the Claims Administrator at the
number on your ID card before requesting a formal appeal. If the Claims Administrator cannot
resolve the issue to your satisfaction over the phone, you have the right to file a formal appeal as
described below. Calling the Claims Administrator alone will not start the formal appeal process.
Request for Review of Adverse Benefit Determinations
If your initial claim is denied in whole or in part and you disagree with the decision, you may
request that the decision or adverse benefit determination be reviewed. An adverse benefit
determination is defined as (a) a denial, reduction, or termination of benefits, or (b) a failure to
provide or make payment (in whole or in part) for a benefit. (A rescission of coverage is also an
adverse benefit determination. Please see “Special Rules for Claims Related to Rescissions” later
in this section for information on how to appeal a rescission.) Within 180 days of the date you
receive an adverse benefit determination with which you disagree, you should submit a request
for review to your Claims Administrator. With the exception of Urgent Claims, all requests for
review should be submitted in writing. Requests for review of adverse benefit determinations
relating to Urgent Claims may be made either orally or in writing.
Your request for review may (but is not required to) include issues, comments, documents,
records, and other information relating to your claim that you want considered in reviewing your
claim. You may request reasonable access to, and copies of, all documents, records, and other
information relevant to your adverse benefit determination without charge.
In reviewing your claim, your Claims Administrator will ensure that your claim is reviewed by
individuals who were not involved in the initial adverse benefit determination. The Claims
Administrator will not defer to the initial claim reviewer's decision and will look at your claim
anew. If your adverse benefit determination was based upon medical judgment, a health care
professional with the appropriate training and experience in the field of medicine involved in the
medical judgment will be consulted during the review of your claim. The health care
professionals will not have been involved in the initial adverse benefit determination (nor a
subordinate of any person previously consulted). You may request information regarding the
identity of any health care professional whose advice was obtained during the review of your
claim.
If the Claims Administrator considers, relies on or generates new or additional evidence in
connection with its review of your claim, you will be provided the new or additional evidence
free of charge as soon as possible and with enough time before a final determination is required
to be provided to you (see the chart under “Determination Upon Request for Review” below) so
that you will have an opportunity to respond. If the Claims Administrator relies on a new or
additional rationale in denying your claim on review, you will be provided with the new or
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additional rationale as soon as possible and with enough time before a final determination is
required to be provided to you (see the chart under “Determination Upon Request for Review”
below) so that you will have an opportunity to respond. You may also review the claim file and
present evidence and testimony.
Determination Upon Request for Review
The time period for deciding a request for review of an adverse benefit determination and
notifying you of such a decision depends upon the type of claim at issue (e.g., pre-service claims
vs. post-service claims). The chart below provides the time periods in which your Claims
Administrator will notify you of its decision on your request for review for each type of claim.
These time periods will not be extended for any reason.
Type of Claim
Deadline for Notifying Claimant of Request for Review Determination
Post-Service Claims 60 days after receipt of the request for review
Pre-Service Claims 30 days after receipt of the request for review
Urgent Claims No later than 72 hours after receipt of request for review, taking into account the
medical urgency
If upon review the denial of your claim is upheld, in whole or in part, you will receive a notice
from your Claims Administrator which includes:
• information about your claim and the reason(s) the denial was upheld;
• the plan or Program provisions on which the denial is based;
• an explanation of your right to request reasonable access to and copies of the relevant
documents, records, and information used in the claims process without charge;
• a description of any voluntary appeal procedures offered by the plan (although currently
the plan does not have such voluntary appeal procedures);
• a statement of your right to file a civil action under section 502(a) of ERISA if your claim
is denied upon a request for review;
• a statement indicating whether an internal rule, guideline, protocol or other similar
criterion was relied on in deciding your claim and information explaining your right to
request such information, free of charge;
• if an adverse benefit determination is based on medical necessity or experimental
treatment or a similar exclusion or limitation, an explanation of the scientific or clinical
judgment for the determination applied to your medical circumstances;
• description of the plan’s standard, if any, used in denying the claim (e.g., if a medical
necessity standard is used to deny the claim, the notice must describe the medical
necessity standard);
• discussion of the decision;
• description of available external review processes; and
• disclosure of availability of and contact information for any applicable office or health
insurance consumer assistance or ombudsman, if any, established by the Department of
Health and Human Services to assist in internal claims, appeals and external review
process.
For Urgent Claims, the notice may be made by telephone, facsimile, or other similarly prompt
method.
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For Pre-Service and Urgent Claims only, you will receive notice for approved claims as well as
denied claims.
Special Rules for Concurrent Claims (Medical)
Concurrent claims are claims that relate to a previously approved period of time or number of
treatments for an ongoing course of medical treatment.
If you request an extension of a previously approved period of time or number of treatments and
your claim involves urgent care, the Claims Administrator will decide your claim and notify you
of its decision within 24 hours after receipt of your request; provided your claim is filed at least
24 hours prior to the end of the approved time period or number of treatments. If you did not file
the claim at least 24 hours prior to the end of the approved treatment, the claim will be treated as
and decided within the timeframes for an Urgent Claim as described under “Initial Claim
Determination” earlier in this section. If your claim does not involve urgent care, then the time
periods for deciding pre-service claims and post-service claims, as applicable, will govern.
If there is a reduction in or termination of the ongoing course of treatment for which you have
received prior approval (for reasons other than amendment or termination of the plan), the
Claims Administrator will notify you. This reduction or termination of an ongoing course of
treatment will be considered an adverse benefit determination. You will receive notice in
advance of the date the reduction or termination will occur so that you have a sufficient
opportunity to appeal the decision before the reduction or termination occurs. If you appeal the
reduction or termination of your ongoing course of treatment, the reduction or termination will
not occur before a final decision is made on your appeal. If you disagree with the reduction or
termination, you should follow the procedures described previously for requesting a review of an
adverse benefit determination. The time periods that will apply to your request will depend on
the nature of your concurrent claim (e.g., urgent vs. pre-service vs. post-service).
Special Rules for Claims Related to Rescissions
A rescission is a discontinuation of coverage with retroactive effect. Coverage may be rescinded
because the individual or the person seeking coverage on behalf of the individual commits fraud
or makes an intentional misrepresentation of material fact, as prohibited by the terms of the plan.
However, some retroactive cancellations of coverage are not rescissions. Rescissions do not
include retroactive cancellations of coverage for failure to pay required premiums or
contributions toward the cost of coverage on time. A prospective cancellation of coverage is not
a rescission. If your coverage is going to be rescinded, you will receive written notice 30 days
before the coverage will be cancelled. A rescission will be considered an adverse benefit
determination. You will then have the opportunity to appeal the rescission as described under
“Request for Review of Adverse Benefit Determinations” earlier in this section. Internal request
for review of rescission denials should be submitted to, and will be decided by, the U.S. Bank
Benefit Claim Subcommittee. For purposes of rescissions, the U.S. Bank Benefit Claim
Subcommittee will be the Claims Administrator.
External Appeal Process
If, upon review, your claim is still denied and you disagree with the Claims Administrator's
decision, you may submit your claim to the external appeal process described below if your
claim denial involves either medical judgment or a recission. Other types of claim denials are not
eligible for external appeal. This step is not mandatory.
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Retiree Health Care SPD Effective January 1, 2012
In most circumstances, before you may submit your claim to the external appeal process, you
must first follow the claims procedures outlined above by filing an initial claim and a request for
review of an adverse benefit determination with your Claims Administrator. However, in certain
circumstances (described below), you may receive an expedited external review. In this case, you
may not have to exhaust the internal claims process before filing a request for external review.
Within four months of the date you receive notice that, upon review, your claim continues to be
denied, you may submit your claim to the external appeal process by writing to your Claims
Administrator.
Your written external appeal may (but is not required to) include issues, comments, documents,
records, and other information relating to your claim that you want considered in reviewing your
claim.
Under the following circumstances, you can request an expedited external review:
• If you have received an initial claim determination that denied your claim, you may request
expedited external review if (1) you filed a request for an Urgent Care appeal AND (2) the
time for completing the internal review process would seriously jeopardize life, health, or
ability to regain maximum function.
• If you appealed your initial claim denial and received a final internal claim denial and (1) the
time for completing the external review process would seriously jeopardize life, health, or
ability to regain maximum function OR (2) the denial of the internal appeal concerned the
admission, availability of care, continued stay, or health care item or service for which you
received emergency services, but you have not been discharged from a facility.
Preliminary Review of Standard (Not Expedited) External Claims
Within five days of receipt of the external review request, your Claims Administrator will
complete a preliminary review of your request to determine if your claim is eligible for external
review. Your claim is eligible for external review if:
• you are or were covered under plan when the item or service was requested or provided,
• the claim or appeal denial does not relate to your failure to meet the plan’s eligibility
requirements,
• you have exhausted the internal appeal process (unless you are not required to exhaust the
internal claims procedures), and
• you have provided all information and forms required to process external review.
Within one business day after completion of the preliminary review, your Claims Administrator
will notify you in writing regarding whether your claim is eligible for external review. If your
request was not complete, the notice will describe information or materials needed to complete
request. You will have until the end of the four month period you had to file a request for an
external review or 48 hours (whichever is later) to complete your request. If your request is
complete but not initially eligible for external review, the notice will include the reasons your
request was ineligible and contact information for the Employee Benefits Security
Administration.
External Review Process
If your Claims Administrator determines your claim is initially eligible for external review, your
claim will be assigned to an independent review organization. The independent review
organization will notify you that your claim is initially eligible for external review and that the
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review process is beginning. The notice will also inform you that you have 10 business days
following receipt of the notice to provide additional information to the independent review
organization for it to consider. If however, the independent review organization determines that
your claim does not involve either medical judgment or a rescission, it will notify you that the
claim is not eligible for external review.
If your claim is eligible, the independent review organization will not defer to the decisions made
during the internal review process and will look at your claim anew. The independent review
organization will consider all the information and documents that it receives in a timely manner
when making its decision.
The independent review organization and/or your Claims Administrator will provide written
notice of the final external review decision within 45 days after it receives the request for
external review.
If the independent review organization reverses the Claims Administrator’s denial of your claim,
the decision will be binding on the plan, and the plan must immediately provide coverage or
payment, regardless of whether it intends to seek judicial review of the external review decision
and unless or until there is a judicial decision otherwise.
Expedited External Review Process
In general, the same rules that apply to standard external review apply to expedited external
review, except that the timeframe for decisions and notifications is shorter.
Expedited Preliminary Review: Your Claims Administrator will immediately conduct a
preliminary review to determine if your claim is initially eligible for external review. After the
preliminary review is completed your Claims Administrator will immediately notify you of its
determination. If your request was not complete, the notice will describe information or materials
needed to complete the request. You will have until the end of the four month period you had to
file a request for an external review or 48 hours (whichever is later) to complete your request.
Expedited External Review: If your claim is initially eligible for expedited external review, your
claim will be assigned to an independent review organization. The independent review
organization will provide you its final decision as expeditiously as your medical condition or
circumstances require, but in no event will the notification be provided later than 72 hours after
the independent review organization receives the request for expedited external review. If the
notice of the decision is not provided in writing, then the independent review organization must
provide you with written confirmation of the decision within 48 hours after the notice of decision
was first provided to you by other means.
The period during which your external appeal is brought and decided will not count against the
time period permitted for you to bring a lawsuit (i.e., any applicable statute of limitations will be
tolled). Submitting your claim to the external appeal process is not a prerequisite and does not
prevent you from filing a civil action under section 502(a) of ERISA once the claim-and-review
procedure has been completed.
Failure to Strictly Adhere to Internal Claims and Appeals Process
Effective January 1, 2012, (or a later date if the compliance deadline is further extended), if the
Claims Administrator fails to strictly adhere to the internal ERISA claims procedures described
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Retiree Health Care SPD Effective January 1, 2012
above and claims and appeals guidance issued by the Department of Labor, you will be deemed
to have exhausted the internal claims and appeals process and you may initiate an external
review or bring suit under section 502 of ERISA. However, this strict adherence rule does not
apply if the violation is:
• very minor,
• non-prejudicial,
• attributable to a good cause or matters beyond the Plan’s control,
• made in the context of an ongoing good faith exchange of information, and
• not reflective of a pattern or practice of noncompliance.
If the claims procedures have not been strictly adhered to, you have the right to request a written
explanation of the violation from the Claims Administrator. Within 10 days after receipt of your
request, the Claims Administrator will provide you an explanation of the basis, if any, for
asserting the violation should not cause the internal claims and appeals process to be deemed to
be exhausted. If an external reviewer or court rejects your request for immediate review, you will
be able to resubmit your claim and pursue the internal claims process.
General Rules for Internal and External Claims
• Your initial claim, any request for review of an adverse benefit determination, and any
request for external appeal must be made in writing, except for requests for review of
adverse benefit determinations relating to Urgent Claims, which may also be made orally.
• You must follow the claim-and-review procedure contained in this SPD carefully and
completely and you must file your claim before any applicable deadlines. If you do not
do so, you may give up important legal rights.
• Your casual inquiries and questions will not be treated as claims or requests for a review
or submissions to the external appeal process,
• You may have a lawyer or other representative help you with your claim at your own
expense (the Claims Administrator or U.S. Bank may require written authorization to
verify that an individual has been authorized to act on your behalf, except that for Urgent
Claims a health care professional with knowledge of the claimant's medical condition
will be permitted to act as an authorized representative).
• You are entitled to receive, upon request and free of charge, reasonable access to, and
copies of, all documents, records, and other information relevant to any adverse benefit
determination. You will also be allowed to review the claim file and present evidence and
testimony as part of the internal claims and appeal process.
• You must comply with any additional requirements for filing a claim (e.g., using a
specific claim form) imposed by the Claims Administrator.
Exhaustion of Administrative Remedies
The exhaustion of the claim-and-review procedure (with the exception of the external claim
review process) is mandatory for resolving every claim and dispute arising under this Program
prior to initiating legal action (except if the internal claim and appeal process is deemed
exhausted under the rules in the section “Failure to Strictly Adhere to Internal Claims and
Appeals Process”). In any legal action brought after you have exhausted the administrative
remedies, all determinations made by the Claims Administrator, U.S. Bank or other fiduciary,
shall be afforded the maximum deference permitted by law.
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Retiree Health Care SPD Effective January 1, 2012
Time Limitations for Commencing a Claim
You must submit your claim for benefits within one year after whichever is earliest – the date on
which you were denied benefits or received benefits at a different level than you believed the
Program provides, or the date you knew or reasonably should have known of the principal facts
on which your claim is based. After you file your claim, you must complete the entire claim-andreview
procedure (with the exception of the external claim process) before you can sue over your
claim. It is important that you include all the facts and arguments that you want considered
during the claim-and-review procedure.
Time Limitations for Commencing a Legal Action
If you file your claim within the required time and complete the entire claim-and-review
procedure (including, if you pursue it, completion of external review), any lawsuit must be
commenced within six months after the claim-and-review procedure is complete. In any event,
you must commence the suit within two years after whichever is earliest – the date on which you
were denied benefits or received benefits at a different level than you believed the Program
provides; or the date you knew or reasonably should have known of the principal facts on which
your claim is based.
Venue for Legal Action
Any legal action filed with respect to the Plan must be filed in the federal court for Minnesota
located in Hennepin County.
Applicable Law for Legal Action
If federal law is not controlling, the Plan shall be construed and enforced in accordance with the
laws of the State of Minnesota (except that the state law will be applied without regard to any
choice of law provisions).
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Retiree Health Care SPD Effective January 1, 2012
COST OF RETIREE HEALTH CARE COVERAGE
The cost of retiree health care coverage for participants in the Program is based on claims
experience and medical expense projections. The cost is generally adjusted on an annual basis
and changes on January 1. The cost could, however, in U.S. Bank’s discretion, be changed more
frequently.
All retirees who satisfy the criteria set forth in the “Eligibility and Enrollment” section can enroll
themselves and any covered dependents (spouse/domestic partner/children or grandchildren) in
retiree health care coverage by paying the full cost established by the Program for coverage for
that year.
Retiree Health Care Credits
Eligible employees who satisfy age and Years of Service requirements described below are
deemed eligible to earn up to a maximum of 15 years of retiree health care “credits” that can be
applied toward the cost of their retiree health care coverage under the Program.
Effective January 1, 2002, the credits replace the subsidy structure in place under the West
Retiree Health Care Program (West employees retiring in 2002 may have a choice between the
fixed subsidy option and the health care credits option – please see the section labeled “Special
Transition Rule for West Employees Retiring in 2002”) and, effective January 1, 2003, replace
the current subsidy formula in effect for employees of the former Mercantile.
Here is how the retiree health care credits work:
Eligibility for Retiree Health Care Credits
While you are working for U.S. Bank, you are eligible (unless you are classified as a U.S. citizen
working abroad as discussed below) to accumulate credits at the earlier of the date on which you
are at least:
• Age 45 with 15 “Years of Service”; or
• Age 50 with 10 “Years of Service”.
See “Years of Service” in the “Glossary of Terms” section in this SPD for more information
about how Years of Service are calculated. Any year that you are employed by U.S. Bank but do
not have a Year of Service (for example a year in which you work less than 1,000 hours) will not
count as a Year of Service for eligibility to begin accumulating credits.
Accumulating Retiree Health Care Credits
If you have satisfied the 45/15 age and Years of Service rule or the 50/10 age and Years of
Service rule explained above, you begin to accumulate credits. You get a $1,200 “credit” for that
year and each subsequent year in which you have a Year of Service and are employed by
U.S. Bank on the last business day of the year. (For example, if you have a Year of Service but
terminate on December 15, you will not receive credits for that year.) You can receive up to a
maximum of 15 years of retiree health care credits.
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Retiree Health Care SPD Effective January 1, 2012
If you accumulate credits and then continue to work for U.S. Bank but do not earn a Year of
Service in a particular year, you will retain your previously accumulated credits but will not
accumulate credits for that year. Future employment in which you have a Year of Service will
result in additional credits, up to the 15-year maximum.
U.S. Bank has reserved the right to increase or decrease the amount of the retiree health care
credit.
Nature of Retiree Health Care Credits and Reservation of Rights to Change
Credits
The credits you accumulate toward retiree health care coverage are not like accounts in a 401(k)
or pension plan. No trust holds these credits, and there is no bank account in which the credits
are deposited. This means that as long as U.S. Bank keeps the credits structure in place in its
Retiree Health Care Program, it will, for bookkeeping purposes, keep a record of any credits you
accumulate. Then, if you are eligible for and enroll in the Program when you terminate, you can
apply the accumulated credits toward retiree health care coverage for yourself and any covered
dependents.
If, however, you do not elect U.S. Bank retiree health care coverage at the time of your
termination or you are not eligible for retiree health coverage when you terminate (for example if
you are not a participant in the active employee Health Care Program at the time of your
termination), your credits are forfeited under all circumstances. Once forfeited, retiree health
care credits are never recovered or restored even if, for example, you return to work for U.S.
Bank. Also credits cannot be paid out to you or used for any other purpose than payment toward
U.S. Bank retiree health care coverage under the Program.
Additionally, U.S. Bank is not obligated to continue either the Program or the retiree health care
credits toward the cost of the coverage. U.S. Bank could, before or after your termination of
employment, terminate the coverage altogether or could amend the Program to eliminate or
change (including reducing) the credits – including any credits you have already accumulated.
This is because retiree health care coverage is not a ‘vested’ benefit and U.S. Bank has retained
its full authority and discretion to amend or terminate the Program.
Interest on Retiree Health Care Credits
Credits are deemed to receive interest payments of 5.5% annually. For example, if you are 45
with 15 years of service as of December 31, 2011, and have a Year of Service in 2011, you have
a $1,200 credit as of December 31, 2011. At the end of 2012, your $1,200 credit from 2011 is
deemed to increase an additional 5.5% ($66) to $1,266. (If you had a Year of Service in 2012
and were employed on the last business day of the year, you would also be deemed to receive an
additional $1,200 contribution on December 31, 2012.) U.S. Bank has reserved the right to
increase or decrease the interest rate.
If you terminate your employment with U.S. Bank and enroll in the Program, your remaining
credit balance (after deductions from the account toward the cost of coverage) as of each
December 31 will be deemed to gain interest at the established interest rate. If you do not enroll
in the Program at termination or if you leave U.S. Bank before you are eligible for retiree health
care coverage, your credits and any deemed interest are lost.
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Retiree Health Care SPD Effective January 1, 2012
Long-Term Disabilities and Retiree Health Care Credits
Even if you have a “Year of Service,” you will not accumulate retiree health care credits for any
year in which on the last day of the year you are receiving long-term disability benefits under
any long-term disability plan sponsored by U.S. Bancorp. If you accumulated retiree health care
credits previously, however, you will retain those credits while you receive long-term disability,
and the credits will continue to earn interest. Years in which you are receiving long-term
disability benefits on December 31 may however count as Years of Service toward the 45/15 or
50/10 age and Years of Service rule to begin accumulating credits.
Severance and Retiree Health Care Credits
Former employees receiving severance pay will not accumulate any retiree health care credits
under the Program during the severance period.
U.S. Citizens Working Overseas Do Not Earn Credits
You will not be eligible to earn credits for any year in which on the last day of the year you are
classified for payroll purposes as a U.S. citizen working overseas. If, however, you accumulate
annual credits and then transfer overseas, you will retain any accumulated credits and those
credits will continue to earn deemed interest.
Years of Service in which you are classified as a U.S. citizen working overseas on December 31
will, however, count toward the 45/15 or 50/10 age and Years of Service rule to begin
accumulating credits. Additionally, periods in which you are classified as a U.S. citizen working
overseas on December 31 can count toward the age 55 and five Years of Service requirement for
participation in the Program. Finally, if you are classified as a U.S. citizen working overseas
when you terminate, the eligibility requirement that you be enrolled in a U.S. Bank active
employee health care plan at the time of your termination will be waived. All other eligibility
requirements must be satisfied.
Paying for Retiree Health Care Coverage with Credits
If you terminate and are eligible for retiree health coverage, and elect coverage, approximately
two-thirds of the annual medical cost for the coverage you will have elected will be offset against
your accumulated credits, and you will pay the remaining approximately one-third cost out of
pocket. If eligible for the Program, you will receive information about options for paying your
out of pocket portion of the cost at the time of your termination.
Approximately two-thirds of the medical cost will continue to be deducted from your account
until the credits are insufficient to cover two-thirds of the cost. The credit balance will be
reviewed January 1 of each year and if the credits will not cover two-thirds of the cost of your
premium for the entire year, then the balance will be divided by twelve to determine the amount
used to offset your premium payment. If your rate changes during the plan year, the dollar
amount used to offset your premium payment will be recalculated. After your health care credit
balance is depleted, you can continue to participate in the Program by paying 100% of the cost
out of pocket.
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Retiree Health Care SPD Effective January 1, 2012
If you have elected coverage for dependents (spouse/domestic partner/children or grandchildren),
the annual medical cost will include their coverage. Approximately two-thirds of the total elected
coverage will be offset against the accumulated credits, to the extent available.
If You Die with Accumulated Credits
Your credits can be transferred to an eligible spouse or domestic partner, if you either die while
employed (after having reached at least age 55 with 5 Years of Service) with accumulated credits
or die while participating in the Program with remaining credits. Your spouse/domestic partner
can use the credits for two-thirds of the annual cost of retiree health care coverage. This is the
only use for the credits; he or she will not receive any cash payment or be able to use the credits
for any other purpose. After the credits are depleted by the spouse/domestic partner, he or she
can continue to participate in the Program by paying 100% of the cost.
Your spouse/domestic partner is the only dependent eligible for transferred credits; no nonspousal
dependents receive transferred credits. However, if there are additional eligible
dependents (such as a dependent child) receiving coverage at the time of your death, your spouse
would continue to receive family coverage and the health care credits would continue to pay
two-thirds of the cost until the credits are insufficient to cover two-thirds of the cost. Special
payment rules apply in the year when the credits become insufficient to cover two-thirds of the
cost. After your health care credit balance is depleted, your spouse/domestic partner and your
covered dependents can continue to participate in the Program by paying 100% of the cost.
Special Transition Rules
Special Transition Retiree Health Care Credit for Past Service
The Program included a special one-time transition rule. Any employee who was eligible for
credits as of December 31, 2001 (e.g. had a Year of Service in 2001 and was employed on
December 31, 2001) received up to a maximum of five years of credits, reflecting past Years of
Service. For example, if on January 1, 2002, you were age 55 with 20 Years of Service, and you
had a Year of Service in 2001, you received five years of deemed credits. If, as of January 1,
2002, you were age 45 with 18 Years of Service, and you had a Year of Service in 2001, you
received one year of deemed credits. This is a special one-time rule. If you received special
transition credits, they will count toward your maximum 15 years of credits under the Program.
You will not be eligible to receive a transition credit for past service if:
• you were classified as a U.S. citizen working overseas as of December 31, 2001;
• you were receiving long-term disability benefits as of December 31, 2001; or
• you were on severance as of December 31, 2001.
Even though Mercantile Employees could not use retiree health care credits until their retirement
on or after January 1, 2003, the special one-time transition credit was calculated for those
Mercantile Employees who satisfied the requirements as described in this section. In 2003,
therefore, Mercantile Employees satisfying the age and Year of Service requirements received up
to five years of special transition credits (based on eligible service, if any, through December 31,
2001), interest on any transition credits and potentially an additional credit for 2002 (if they had
a Year of Service in 2002 and were employed by U.S. Bank at the end of 2002). If you are a
Mercantile Employee and retired in 2002, however, you did not receive any retiree health care
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Retiree Health Care SPD Effective January 1, 2012
credits. Your eligibility, if any, for a subsidy was determined under the terms of the Mercantile
Bancorporation Inc. Health Care Plan.
Special Transition Rule for West Employees Retiring in 2002
A special transition rule applied to West employees who retired in 2002. If you were a West
employee who retired in 2002, you were given the opportunity to pick between the former Fixed
Subsidy of the U.S. Bank Retiree Health Care Program (if you satisfied the additional
requirement that your age and Years of Service totaled at least 65) and the new retiree health
care credits. After retirement, you either received the former Fixed Subsidy or the new credits;
but not both.
If you were eligible and chose the Fixed Subsidy, it applied only until you are age 65 and, after
age 65, there would be no further subsidy. Note that to be eligible for the Fixed Subsidy, in
addition to satisfying the rules to participate in the Program generally (see the “Eligibility and
Enrollment” section in this SPD), your age and Years of Service must have totaled at least 65. If
you elected the Fixed Subsidy, waived coverage, or did not return your enrollment form by the
enrollment deadline, you forfeited any retiree health care credits you might otherwise have
accumulated as of your retirement. Additionally, if you retired under the Fixed Subsidy structure,
you were eligible to elect COBRA for 18 months and then enroll in retiree health care coverage,
or to enroll yourself or a dependent after loss of other coverage, if when you and/or the
dependent initially declined coverage under the Fixed Subsidy, you declined it because of the
other coverage. If, alternatively, you were eligible and enrolled yourself and any eligible
dependents in the health care credits option at retirement, you forfeited your opportunity to enroll
yourself and any eligible dependents in the Fixed Subsidy option.
All other features of the U.S. Bank Retiree Health Care Program will apply to your coverage.
Special Transition Rule for Mercantile Employees Retiring in 2002
• If you were a Mercantile employee and retired in 2002, your eligibility, if any, for a subsidy
was determined under the terms of the Mercantile Bancorporation Inc. Health Care Plan. No
Mercantile employees who retired in 2002 were eligible for or received retiree health care
credits. Otherwise, the terms of the Program would apply to Mercantile employees retiring in
2002.
• For Mercantile Employees who retired on and after January 1, 2003, the subsidy under the
terms of the Mercantile Bancorporation Inc. Health Care Plan was no longer available.
Mercantile Employees who retired on and after January 1, 2003 were eligible for retiree
health care credits if they satisfied the age and Years of Service requirements described in
this SPD.
Special Rules for Retirees Who Terminate and Receive Severance
Some employees may terminate, receive severance pay and then be eligible to enroll in the
Retiree Health Care Program after severance ends. In such cases, the Program’s terms at the time
of termination from U.S. Bank and commencement of severance will determine your eligibility,
if any, for retiree health care. Former employees receiving severance pay will also not
accumulate any retiree health care credits (either the special one-time transition credit or any
additional credits) under the Program during the severance period, even if they are accruing
vesting service for purposes of the U.S. Bank Pension Plan.
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Retiree Health Care SPD Effective January 1, 2012
Here are some examples of how these rules apply:
Harold, age 57, was a West employee who terminated in June 2001 and received severance pay
until February 2002. At the time of his termination, he was eligible for coverage under the West
U.S. Bank Retiree Health Care Program. If he elects coverage under the Program after his
severance ends, he will be treated as if he had retired and enrolled in 2001. He will be eligible for
the former West Fixed Subsidy only. He will not be eligible for any transition credits under the
new Program, nor will he have a choice between the Fixed Subsidy and credits.
Joan, age 59 with 12 Years of Service as of January 1, 2002, is a West employee who terminates
in June 2002 and receives severance pay until February 2003. Joan received a transition credit of
three years of credits (based on her Years of Service) in January 2002. At the conclusion of her
severance, she will be treated as if she had retired in 2002 and will have a choice between the
Fixed Subsidy and the retiree health care credits under the special one-time transition rule for
West retirees. She will not, however, receive any additional credits for 2002.
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Retiree Health Care SPD Effective January 1, 2012
BENEFITS ADMINISTRATIVE INFORMATION
When Coverage Ends
Your coverage under the Program will end when one of the following events first occurs.
For you:
• You die;
• You no longer satisfy the eligibility requirements for participation;
• You fail to pay any required premiums in full by the required due date;
• You request that coverage be terminated;
• You are on active duty military leave deployment for more than 6 weeks or other military
training leave lasting more than 90 days (refer to the “USERRA” section in this SPD); or
• The Program is discontinued or amended so that you lose eligibility.
In addition to the events listed above, coverage for your dependents will end due to:
• Divorce, legal separation or termination of domestic partnership (if you terminate your
domestic partnership, coverage for your partner and any covered dependent(s) of your
partner will end);
• The dependent child reaches his/her 26 th birthday;
• The dependent no longer satisfying the dependent criteria for participation in a plan or
Program;
• For dependent children only, the death of both you (the retiree) and your spouse;
• A decision by you to terminate coverage; or
• You fail to provide requested documentation that proves your dependent’s eligibility for
coverage or the documentation you provide does not verify your dependent’s eligibility for
coverage.
If one of the events listed above occurs, your health care coverage will end on the last day of the
month in which ineligibility occurs.
If you commit an act, practice or omission that constituted fraud, or an intentional
misrepresentation of a material fact, U.S. Bank reserves the right to terminate coverage
retroactively with proper notice.
Failure to Notify U.S. Bank of Dependent Ineligibility
If you do not call the U.S. Bank Employee Service Center within 60 days of the date your
dependent became ineligible, coverage will be cancelled retroactively 60 days from the date you
do contact the service center or the date you fail to provide requested documentation proving
your dependent’s eligibility for coverage. In this event, if your coverage level changed,
premiums for coverage will only be refunded for the period between the date coverage for the
dependent was cancelled and the date your new premiums became effective. You will be
responsible for any claims incurred after the coverage end date. Additionally, your dependent
will not be eligible for COBRA coverage. COBRA will not be offered now or ongoing.
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Retiree Health Care SPD Effective January 1, 2012
USERRA
If you lose coverage for certain benefits (e.g., health coverage) because of duty in the uniformed
services, you and your covered dependents will be entitled to elect certain continuing coverage.
This extended coverage will last no more than 24 months and cannot be extended regardless of
the occurrence of any other subsequent event. This complies with the benefit provisions of the
Uniformed Services Employment and Reemployment Rights Act (USERRA). The uniformed
services are:
• the Armed Forces, the Army National Guard and the Air National Guard (when engaged in
active duty for training, inactive duty training, or full-time National Guard duty);
• the Commissioned Corps of the Public Health Service; and
• any other category of persons designated by the President of the United States in time of war
or emergency.
Situations That Affect Your Coverage
If you die while your family is covered by the U.S. Bank Retiree Health Care Program, under the
current terms of the Program your spouse/domestic partner can continue retiree health care
coverage as long as the Program continues to be available and subject to any changes made to
the Program. In addition, your children can stay covered for as long as they are eligible, and your
spouse/domestic partner continues under the Program. However, your spouse/domestic partner
may not add any dependents to the Program at any time. If after your death, your
spouse/domestic partner also dies, coverage for your covered dependent children will end,
subject under certain circumstances to rights to COBRA. Refer to the “Dependents Continuing
Coverage After It Would Otherwise End — COBRA” section for more information.
Health Coverage Certificates
If you or your dependent(s) lose coverage under the U.S. Bank Retiree Health Care Program,
U.S. Bank, or its designated administrator, will provide a written coverage certification. The
purpose of this certification, called a “certificate of creditable coverage,” is to enable you (and/or
your dependents) to submit the certificate as proof of prior coverage when obtaining new health
coverage.
Certificates will be provided automatically when your (and/or your dependents’) coverage ends
as well as when COBRA coverage (if any) ends. You also have the right to request a certificate
within 24 months from the date your coverage through U.S. Bank ended by contacting the
Claims Administrator’s customer service department.
Dependents Continuing Coverage After It Would Otherwise End — COBRA
In some cases, your spouse and your dependent children may have the option of continuing
health care coverage when coverage under the U.S. Bank Retiree Health Care Program would
otherwise end. This continuation right is provided in accordance with the Consolidated Omnibus
Budget Reconciliation Act of 1986 (COBRA). Your dependents will have to pay for such
coverage.
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Retiree Health Care SPD Effective January 1, 2012
Although domestic partners and the domestic partner’s dependent(s) are not entitled to
continuation coverage under the provisions of COBRA, under certain circumstances as described
below, health care coverage may be continued for your domestic partner and/or your domestic
partner’s dependent(s).
Review this SPD and the documents governing the plan about the rules that apply to your
dependent’s COBRA continuation rights.
Restrictions
Your spouse, domestic partner and dependents can continue only the coverage they were
enrolled in prior to becoming eligible for COBRA. In some cases, the same options and levels of
coverage will be offered. However, if they were enrolled in an option that has a service area and
they no longer reside in that service area, another option will be offered based on their new
address. In other cases, the same options are not available so another option would be offered.
Although you can decrease coverage under COBRA, you are not allowed to increase coverage
unless you have newly eligible dependents. You must call the U.S. Bank Employee Service
Center at 1-800-806-7009 and complete the enrollment process within 60 days of the qualifying
event (birth, marriage, etc.). Your COBRA information will tell you how to add new dependents.
Your benefit changes will be effective on the first day of the month following the date you make
your election, with two exceptions: (1) if you make your election on the first day of the month,
your coverage becomes effective on that day; and (2) if you are adding a newborn or newly
adopted child (or a child placed with you for adoption), health coverage for that dependent, and
for any other dependent you add due to that event, will be retroactive to the date of the event.
(See the section “Eligibility and Enrollment” in this SPD for a description of eligible
dependents.)
Qualifying Events — Length of Coverage
Coverage can be continued for up to a total of 36 months. Your eligible dependents can choose
to continue coverage if it would otherwise end because of any of these events:
• for dependent children if you die and your spouse is not covered by the Program;
• your divorce or legal separation;
• termination of domestic partnership (in this even, dependents of your domestic partner also
would lose coverage and be eligible to continue coverage;
• change in a dependent's status (for example, a dependent reaches age 26, or is no longer
considered an eligible dependent under the Program) ; or
• U.S. Bank’s commencement of a bankruptcy, under Title 11, United States Code.
Electing Continued Coverage
If your dependents become eligible for continued coverage because of your death, they will be
notified of their COBRA options within 44 days from the date their coverage ends. The notice
will indicate the cost for continued coverage.
If continuation is a result of divorce, legal separation, termination of domestic partnership or
change in dependent status, your dependents must call the U.S. Bank Employee Service Center
within 60 days from the date of the event to qualify for continued coverage. The COBRA
Administrator will then provide the forms needed to elect continued coverage. If your
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Retiree Health Care SPD Effective January 1, 2012
dependents do not call the U.S. Bank Employee Service Center within this time frame,
COBRA continuation will not be available.
For coverage to continue, the U.S. Bank Employee Service Center must receive completed
election forms within 60 days after whichever is later:
• the date the coverage would otherwise end; or
• the date your dependents are provided notice of their right to continue coverage.
Although your dependents have 60 days in which to make their decision, COBRA coverage is
not reinstated back to the date the Retiree Health Care Program coverage ended until your
dependents return the election forms and make full payment for coverage. Once their election
form and payment are received, it generally takes about three weeks for their coverage to be
reactivated. Until coverage is reactivated, your dependents must pay for services. When their
coverage is reactivated, they can then submit the bills for reimbursement.
When Continued Coverage Ends
Continued coverage will end before the 36-month limit and will not be reinstated if:
• Your dependent(s) fail to pay the required premiums in full by the specified deadlines
(checks returned for insufficient funds do not qualify as payment and special rules for partial
payment may apply). It is your dependent's responsibility to make payment in full by the
required due date each month. They will not receive a reminder notice.
• Your dependent(s) become covered under another group plan after the date COBRA is
elected (unless the plan includes pre-existing condition limitations that apply to your
dependent(s)).
• U.S. Bank no longer offers group health coverage to its employees or retirees.
• Your dependent(s) become entitled to Medicare benefits after the date COBRA is elected.
• It is determined that your dependent does not meet eligibility requirements or you fail to
provide documentation verifying your dependent’s eligibility.
Cost of Continued Coverage
During the COBRA continuation period your dependents will pay the full cost of coverage on a
monthly basis as well as an additional 2% for administrative expenses each month.
Your dependents have 45 days from the date continuation coverage is elected to make the first
premium payment. Subsequent premium payments are due in full by the first day of each month.
Information regarding payment deadlines will be included with the information you receive
regarding continuation. If the first payment is not made in full within the 45-day period (checks
returned for insufficient funds do not qualify as payment and special rules for partial payments
may apply), no COBRA coverage will be provided. If any subsequent payment is not made in
full within 30 days of the first day of the month (checks returned for insufficient funds do not
qualify as payment and special rules for partial payments may apply), coverage will be cancelled
retroactive to the end of the last month for which payment was made. Your dependents will not
receive a reminder notice. Once coverage is cancelled, it will not be reinstated.
U.S. Bank reserves the right to change premiums at any time and as permitted by law.
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Retiree Health Care SPD Effective January 1, 2012
Conversion Privilege
If your dependents continued Program coverage throughout the COBRA maximum coverage
period by making all required premium payments, they may be able to convert all or part of their
coverage to individual policies at the end of that maximum coverage period. If they convert to
individual policies, no evidence of insurability will be required. More information is available
from the appropriate medical Claims Administrator.
Important Facts About Your Program
This section includes some facts about your U.S. Bank benefits and other benefit plans and
programs, collectively referred to hereafter as “Plans.” The Plans are identified as follows:
Official Plan Name Plan Type Plan Number
U.S. Bank Comprehensive
Welfare Benefit Plan*
Welfare Plan 518
* The plan administrator has chosen to prepare more than one summary plan description for the U.S. Bank
Comprehensive Welfare Benefit Plan pursuant to 29 CFR §2520.102-4. The list of the separate summary plan
descriptions required pursuant to 29 CFR §2520.104a-3 follows.
1. The summary of the Severance Pay Program for certain full- or part-time employees of U.S. Bank who are not
classified as temporary employees, and for certain former employees of businesses acquired by U.S. Bank who
are specifically declared to be covered under the Program.
2. The summary of the Health Care Program and the U.S. Bank Wellness Program for certain persons classified by
U.S. Bank as employees.
3. The summary of the Dental Care Program for certain persons classified by U.S. Bank as employees.
4. The summary of the Retiree Health Care Program (including the separate summary provided only to
participants enrolled in an HMO benefit option) for certain retirees of U.S. Bank or U.S. Bancorp who are/were
enrolled in a U.S. Bank or Health Care plan at termination of employment.
Reports on the Plan are identified and filed with the federal government using an Employer
Identification Number (EIN) assigned by the Internal Revenue Service. The EIN for U.S. Bank is
41-0255900. The address is:
U.S. Bancorp Center
800 Nicollet Mall
Minneapolis, MN 55402.
Amendment or Termination of the Program
U.S. Bank has reserved the right to amend the U.S. Bank Retiree Health Care Program including
any Program or option offered under the plans, by written action of the Benefits Administration
Committee of U.S. Bank (and the Severance Administration Committee for severance plans or
programs) at any time, for any reason and in any respect at its sole discretion. U.S. Bank’s right
to amend or terminate the Program includes, but is not limited to, changes in the eligibility
requirements, premiums or other payments charged, availability and/or amount of retiree health
care credits or subsidies, benefits provided and termination of all or a portion of the coverages
provided under the Program. If the Program is amended or terminated, you will be subject to all
the changes effective as a result of such amendment or termination, and your rights will be
reduced, terminated, altered or increased accordingly, as of the effective date of the amendment
or termination. You do not have ongoing rights to any Program benefit, other than payment of
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Retiree Health Care SPD Effective January 1, 2012
any eligible expenses you incurred or benefits to which you become otherwise entitled prior to
the Program amendment or termination.
If the Program is terminated and replaced by a new plan(s), you can enroll in the new plans if
you meet eligibility requirements. If new plans are not established, you may be eligible to
continue your retiree health care coverage or, under certain circumstances, to convert your
coverage to individual policies. These individual policies will not duplicate your benefits from
U.S. Bank exactly.
Recovery of Excess Payments and Correction of Errors
As a condition of the Program, U.S. Bank has a right to recover any excess benefit payments.
Excess payments can occur if benefits from U.S. Bank, or from U.S. Bank and other sources
combined, exceed those due to you under the Program. Excess payments may also occur if
benefits were paid because of a mistake or incorrect information regarding your or your
dependent’s entitlement to benefits. U.S. Bank will recover any excess amount paid to you by:
• reducing or suspending future benefit payments;
• requesting direct payment from you;
• withholding any payments from U.S. Bank otherwise due you, if permitted by law; or
• any other method allowed by law.
The company also may correct any errors that may occur in administering the Program.
Erroneous contributions and/or benefit payments can be returned to the company as permitted by
law. Contributions may also be returned if they do not meet the requirements for deductibility
under applicable tax laws.
Reimbursement and Subrogation
This Plan maintains both a right of reimbursement and a separate right of subrogation. As an
express condition of your participation in this Plan, you agree that the Plan has the subrogation
rights and reimbursement rights explained below.
The Plan’s Right of Subrogation. If you or your dependents receive benefits under this Plan
arising out of an illness or injury for which a responsible party is or may be liable, this Plan shall
be subrogated to your claims and/or your dependents’ claims against the responsible party.
Obligation to Reimburse the Plan. You are obligated to reimburse the Plan in accordance with
this provision if the Plan pays any benefits and you, or your dependent(s), heirs, guardians,
executors, trustees, or other representatives recover compensation or receive payment related in
any manner to an illness, accident or condition, regardless of how characterized, from a
responsible party, a responsible party’s insurer or your own (first party) insurer. You must
reimburse the Plan to the full extent of benefits paid by the Plan, not to exceed the amount of
recovery, before you or your dependents, including minors, are entitled to keep or benefit by any
payment, regardless of whether you or your dependent has been fully compensated and
regardless of whether medical or dental expenses are itemized in a settlement agreement, award
or verdict.
You are also obligated to reimburse the Plan from amounts you receive as compensation or other
payments as a result of settlements or judgments, including amounts designated as compensation
for pain and suffering, non-economic damages and/or general damages. The Plan is entitled to
recover from any plan, person, entity, insurer (first party or third party), and/or insurance policy
131

Retiree Health Care SPD Effective January 1, 2012
(including no-fault automobile insurance, an uninsured motorist’s plan, a homeowner’s plan, a
renter’s plan, or a liability plan) that is or may be liable for (1) the accident, injury, sickness or
condition that resulted in benefits being paid under the Plan; and/or (2) the medical, dental and
other expenses incurred by you or your dependents for which benefits are paid or will be paid
under the Plan.
Until the Plan has been fully reimbursed, all payments received by you, your dependents, heirs,
guardians, executors, trustees, attorneys or other representatives in relation to a judgment or
settlement of any claim of yours or of your dependent(s) that arises from the same event as to
which payment by the Plan is related shall be held by the recipient in constructive trust for the
satisfaction of the Plan’s subrogation and/or reimbursement claims. Complying with these
obligations to reimburse the Plan is a condition of your continued coverage and the continued
coverage of your dependents.
Duty To Cooperate. You, your dependents, your attorneys or other representatives must
cooperate to secure enforcement of these subrogation and reimbursement rights. This means you
must take no action – including, but not limited to, settlement of any claim – that prejudices or
may prejudice these subrogation or reimbursement rights. As soon as you become aware of any
claims for which the Plan is or may be entitled to assert subrogation and reimbursement rights,
you must inform the Plan by providing written notification to the Claims Administrator of:
• the potential or actual claims that you and your dependents have or may have;
• the identity of any and all parties who are or may be liable; and
• the date and nature of the accident, injury, sickness or condition for which the Plan has or
will pay benefits and for which it may be entitled to subrogate or be reimbursed.
You and your dependents must provide this information as soon as possible and in any event,
before the earlier of the date on which you, your dependents, your attorneys or other
representatives (i) agree to any settlement or compromise of such claims; or (ii) bring a legal
action against any other party.
You have a continuing obligation to notify the Claims Administrator of information about your
efforts or your dependents’ efforts to recover compensation. In addition, as part of your duty to
cooperate, you and your dependents must complete and sign all forms and papers, as required by
the Plan and provide any other information required by the Plan. A violation of the
reimbursement agreement is considered a violation of the terms of the Plan.
The Plan may take such action as may be necessary and appropriate to preserve its rights,
including bringing suit in your name or intervening in any lawsuit involving you or your
dependent(s) following injury. The Plan may require you to assign your rights of recovery to the
extent of benefits provided under the Plan. The Plan may initiate any suit against you or your
dependent(s) or your legal representatives to enforce the terms of this Plan. The Plan may
commence a court proceeding with respect to this provision in any court of competent
jurisdiction that the Plan may elect. The Plan has no obligation to notify you or your
beneficiaries of the intent to exercise one of more of these rights. The failure of the Plan to
provide such a notice shall not constitute a waiver of these rights.
Attorneys’ Fees and Other Expenses You Incur. The Plan will not be responsible for any
attorneys’ fees or costs incurred by you or your dependents in connection with any claim or
lawsuit against any party, unless, prior to incurring such fees or costs, the Program in the
132

Retiree Health Care SPD Effective January 1, 2012
exercise of its sole and complete discretion has agreed in writing to pay all or some portion of
fees or costs. The common fund doctrine or attorneys’ fund doctrine shall not govern the
allocation of attorney's fees incurred by you or your dependents in connection with any claim or
lawsuit against any other party and no portion of such fees or costs shall be an offset against the
Plan’s right to reimbursement without the express written consent of the Claims Administrator.
The Plan Administrator may delegate any or all functions or decisions it may have under this
Reimbursement and Subrogation section to the Claims Administrator.
What May Happen to Your Future Benefits. If you or your dependent(s) obtain a settlement,
judgment, or other recovery from any person or entity, including your own automobile or
liability carrier, without first reimbursing the Plan, the Plan, in the exercise of its sole and
complete discretion, may determine that you, your dependents, your attorneys or other
representatives have failed to cooperate with the Plan’s subrogation and reimbursement efforts.
If the Plan determines that you have failed to cooperate the Plan may decline to pay for any
additional care or treatment for you or your dependent(s) until the Plan is reimbursed in
accordance with the Plan terms or until the additional care or treatment exceeds any amounts that
you or your dependent(s) recover. This right to offset will not be limited to benefits for the
insured person or to treatment related to the injury, but will apply to all benefits otherwise
payable under the Plan for you and your dependents.
Interpretation. In the event that any claim is made that any part of this subrogation and right of
recovery provision is ambiguous or questions arise concerning the meaning or intent of any of its
terms, the Claims Administrator shall have the sole authority and discretion to resolve all
disputes regarding the interpretation of this provision.
Plan Administrator and Plan Sponsor
U.S. Bancorp is the Plan Administrator and Plan Sponsor of the plans and will make
determinations that may be required from time to time in the administration of the plans.
U.S. Bancorp (or the Claims Administrator, to the extent the claims procedure for a benefit
option indicates authority has been delegated to the Claims Administrator or independent review
organization) will have the sole authority, discretion and responsibility to interpret and apply the
terms of the plans and to determine all factual and legal questions under the plans, including
eligibility and entitlement to benefits. Benefits under any plan, Program or option will be paid
only if the Plan Administrator (or the person or entity to whom it has delegated authority)
decides in its discretion that the claimant is entitled to them. Except as noted below for insured
benefits, U.S. Bancorp is also responsible for answering questions about the plans. The address
is:
U.S. Bank – EP-MN-R2BN
Benefits Administration
4000 West Broadway
Robbinsdale, MN 55422-2299
Although U.S. Bank is ultimately accountable for the plans, a third party provides administration
and customer service. For general benefits assistance and information (such as eligibility and
change of address), call the U.S. Bank Employee Service Center at 1-800-806-7009. Specific
coverage and claim-related questions may be better addressed by calling the appropriate
customer service phone numbers listed in the “Important Resources” section of this SPD.
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Retiree Health Care SPD Effective January 1, 2012
Insured Plans, Programs or Options
For each insured plan, program or option, the insurance company will have the sole authority,
discretion and responsibility to interpret and apply the terms of the plan, program or option
insured by the company and to determine all factual and legal questions under the plan, program
or option insured by the company, including entitlement to benefits and the amount of benefit to
be paid under the insurance contract, if any.
Each insurance company is responsible for the payment of all benefits offered under the plan that
it insures. The liability of U.S. Bank is limited to the payment of premiums from its general
assets or, if applicable, from a separate trust fund, called a Voluntary Employees' Beneficiary
Association (VEBA) (see the section “VEBAs and Plan Trustee” in this SPD), to the applicable
insurance company. No covered employee, retiree, dependent or other person shall have any
claim or cause of action against U.S. Bank as to the payment of benefits under any insurance
policy or contract. Each covered person or other claimant entitled to the payment of benefits
under an insured plan shall look solely to the applicable insurance policy or contract, and not to
U.S. Bank or a VEBA for payment of such insured benefits.
Claims Administrator Information
The benefit options listed below are administered through contracts with insurance companies or
third-party administrators:
Benefit Option Name Administration Funding
Early Retiree Medical —
Any location with a BCBS
network
Comprehensive—all locations
not offering the Early Retiree
Medical option
Blue Cross and Blue Shield of
Minnesota
3535 Blue Cross Road
P.O. Box 64560, Rt. P1-2
St. Paul, MN 55164
Blue Cross and Blue Shield of
Minnesota
3535 Blue Cross Road
P.O. Box 64560, Rt. P1-2
St. Paul, MN 55164
Medco Medco Health Solutions of
Irving
8111 Royal Ridge Parkway
Irving, TX 75063
Kaiser Colorado Kaiser Foundation Health Plan
of Colorado
Denver/Boulder
Regional Administrative
Office
10350 E Dakota Avenue
Denver, CO 80247
134
This is a self-funded option, funded by
employer contributions and retiree
contributions. U.S. Bank has committed
itself to paying all eligible medical claims
incurred under the terms of the option.
Blue Cross and Blue Shield of Minnesota
is the medical Claims Administrator.
These are self-funded options, funded by
employer contributions and retiree
contributions. U.S. Bank has committed
itself to paying all eligible medical claims
incurred under the terms of the options.
Blue Cross and Blue Shield of Minnesota
is the medical Claims Administrator.
This is a self-funded option.
U.S. Bank has committed itself to paying
all eligible prescription drug claims
incurred under the terms of the Program.
Medco is the Pharmacy Claims
Administrator.
This is an insured option, funded by
employer contributions and retiree
contributions. U.S. Bank has a contract
with Kaiser Permanente Colorado to
administer and pay all eligible medical
claims incurred under the terms of the
option.

Retiree Health Care SPD Effective January 1, 2012
Benefit Option Name Administration Funding
COBRA For payments to the COBRA
lockbox:
ADP Benefit Services-
COBRA
P.O. Box 7247-0367
Philadelphia, PA 19170-0367
General Benefit
Administration and Customer
Service
Correspondence and
enrollment forms:
ADP COBRA Services
P.O. Box 27478
Salt Lake City, UT 84127-
0478
Hewitt Associates
P.O. Box 785080
Orlando, FL 32878-5080
U.S. Bank Wellness Program U.S. Bank – EP-MN-R2BN
4000 West Broadway
Medica Group Prime
Solution SM Retiree Plan -
Medicare eligible retirees and
dependents in the State of MN
and select counties in ND, SD
and WI. For more
information, refer to the “Your
Health Care Options –
Retirees Age 65 or Older or
Pre-65 and Medicare
Eligible” section in this SPD.
UnitedHealthcare® Group
Medicare Advantage PPO
Retiree Plan
Medicare eligible retirees and
their dependents in locations
other than the State of MN and
select counties in ND, SD and
WI. For more information,
refer to the “Your Health Care
Options – Retirees Age 65 or
Older or Pre-65 and Medicare
Eligible” section in this SPD.
Robbinsdale, MN 55422-2299
Medica Insurance Company
P.O. Box 9310
Minneapolis, MN 55440-9745
UnitedHealthcare
P.O. Box 29650
Hot Springs, AR 71903-9973
135
U.S. Bank has a contract with ADP – Salt
Lake City to administer COBRA.
U.S. Bank has a contract with Hewitt
Associates to handle plan administration
and customer service.
U.S. Bank administers the U.S. Bank
Wellness Program.
This is an insured option, funded by
employer contributions and retiree
contributions. U.S. Bank has a contract
with Medica Insurance Company to
administer and pay all eligible claims
incurred under the terms of the option.
This is an insured option, funded by
employer contributions and retiree
contributions. U.S. Bank has a contract
with Secure Horizons by United
Healthcare to administer and pay all
eligible claims incurred under the terms
of the option.

Retiree Health Care SPD Effective January 1, 2012
Agent for Service of Legal Process
If for any reason you want to seek legal action against the Program, you can serve legal process
on the administrator of the plan, the trustees of the Program and/or the agent for this process. The
agent for legal process is:
General Counsel of U.S. Bank
U.S. Bancorp Center
800 Nicollet Mall
Minneapolis, MN 55402
Plan Year
The plan year for all plans is the calendar year (Jan. 1 – Dec. 31. )
Questions About the Program
If you have questions regarding specific coverage or claims status, contact the Claims
Administrator. If you have general questions about your benefit plans (such as eligibility or
deadlines please call the U.S. Bank Employee Service Center at 1-800-806-7009.
VEBAs and Plan Trustee
U.S. Bank has established a separate trust fund, called a Voluntary Employees’ Beneficiary
Association (“VEBA”) to fund the Retiree Health Care Program, unless otherwise insured. To
the extent any such benefits are not funded through a VEBA or other trust, U.S. Bank will pay
such benefits directly from its general assets. Retiree health care credits are not assets in the
VEBA and are not part of any trust or segregated fund or account.
U.S. Bank Trust National Association is the trustee for the VEBA and may be contacted at:
U.S. Bank N.A.
West Side Flats
60 Livingston Avenue
St. Paul, MN 55107.
ERISA – Your Rights as a Member of the Program
As a participant in the Retiree Health Care Program offered through U.S. Bank and described in
this document, you are entitled to certain rights and protections under the Employee Retirement
Income Security Act of 1974 (“ERISA”). This section summarizes the rights you have as a plan
or Program participant in the Retiree Health Care Program and the U.S. Bank Wellness Program
– rights that ERISA guarantees.
Plan Documents
You can examine, without charge, any of the plan documents – which are in the Plan
Administrator's office in Robbinsdale, Minnesota – during normal work hours. You may also
make a written request to examine, without charge, any of the plan documents at your worksite.
The documents will be sent to your worksite within 10 business days after the date of your
request.
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Retiree Health Care SPD Effective January 1, 2012
If you want to examine a document at your worksite, send your written request to:
U.S. Bank – EP-MN-R2BN
4000 W. Broadway
Robbinsdale, MN 55422-2299
Fax: 763-971-1285
These documents include insurance contracts, annual financial reports and the summary plan
descriptions. You can get copies of these documents by sending a written request to the address
noted above.
The Plan Administrator may make a reasonable charge for the copies ($5 per document as of the
printing of this document).
Summary Annual Report
You will receive a summary of the Program’s annual financial report once a year.
Request for Information
If you make a written request for material that U.S. Bank is required to provide to you, you
should receive the material within 30 days of your request. However, because of matters beyond
the Plan Administrator's control (for example, if your request is lost in the mail), the requested
material may reach you more than 30 days after your request. If you do not receive the material
you requested within 30 days, please call the U.S. Bank Employee Service Center and it will be
sent to you again.
COBRA
The law provides that you and your dependents are entitled to continue health coverage if there is
a loss of coverage under the Program as a result of a qualifying event. You or your dependents
will have to pay for such coverage. Review this SPD and the documents governing the plan
about the rules that apply to you and your dependent’s COBRA continuation rights. While not
covered under the provisions of COBRA, your domestic partner and/or your domestic partner’s
dependents may be eligible to continue coverage if there is a loss of coverage under the Program
as a result of a qualifying event.
Creditable Coverage
You are entitled to a reduction or elimination of exclusionary periods of coverage for preexisting
conditions under your group health plan if you have creditable coverage from another
plan. You should be provided with a certificate of creditable coverage, free of charge, from your
group health plan or health insurance issuer when you lose coverage under the Program, when
you become entitled to elect COBRA continuation coverage and when your COBRA
continuation coverage ceases, if you request it before losing coverage or if you request it up to 24
months after losing coverage. Without evidence of creditable coverage, you may be subject to a
pre-existing condition exclusion for 12 months (18 months for late enrollees) after your
enrollment date in your coverage. For U.S. Bank health care plans, the medical Claims
Administrator will automatically mail the certificate of creditable coverage to your home address
on file. You may also request a certificate by contacting the U.S. Bank Employee Service Center
at 1-800-806-7009.
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Retiree Health Care SPD Effective January 1, 2012
Plan Fiduciaries
The plan fiduciaries are responsible for the proper operation of the Program. They have a duty to
act prudently and in the sole interest of Program participants and beneficiaries.
Benefits Claims and Legal Actions
If you have any questions or problems concerning any of your Program benefits or about
applying for benefits, please call the U.S. Bank Employee Service Center at 1-800-806-7009. If
you have a claim for benefits that is denied in whole or in part, you should receive a written
explanation of the reason for denial. You have the right to have the Plan Administrator review
and reconsider your claim.
If you have completed the appeals process, your claim for benefits is denied (as described in this
SPD) and you believe you are entitled to the benefits you claimed, you can take your case to
federal or state court. If you discover that a plan fiduciary is misusing the plan's money or if you
are discriminated against for exercising your rights under ERISA, you can file suit in a federal
court or ask the U.S. Department of Labor for help. If you make a written request for material
and do not receive the material within 30 days after your request, you can bring suit if there is no
valid reason for the delay. In this situation, the court can require the Plan Administrator to
provide the material and pay you up to $110 a day until you receive the materials.
If you bring suit in federal or state court to protect any of the ERISA rights discussed in this
section, the court will decide who will pay court costs and legal fees. If you win your case, the
court may ask that the losing party pay these costs and fees. If you lose your case – for example,
if the court finds your claim is frivolous, the court may ask you to pay these costs and fees.
Exercising Your ERISA Rights
The law provides that you will not be fired or discriminated against in any way for the sole
purpose of preventing you from getting plan benefits or from exercising the rights you have as a
plan member under ERISA.
If you have any questions about your rights under ERISA or if you need assistance in obtaining
documents from the Plan Administrator, you should contact the nearest office of the Employee
Benefits Security Administration (formerly known as Pension and Welfare Benefits
Administration), U.S. Department of Labor, listed in your telephone directory, or the Division of
Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S.
Department of Labor, 200 Constitution Avenue NW, Washington, DC 20210. You may also
obtain certain publications about your rights and responsibilities under ERISA by calling the
publications hotline of the Employee Benefits Security Administration.
HIPAA Privacy
The information that follows describes how medical and dental information about you may be
used and disclosed, and how you can get access to this information. For the Program, these
regulations took effect April 14, 2003.
The Health Insurance Portability and Accountability Act (“HIPAA”) is a federal law designed to
increase the portability of health insurance and protect health information. As part of HIPAA, the
Department of Health and Human Services, in cooperation with the Department of Labor and
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Retiree Health Care SPD Effective January 1, 2012
Department of Treasury, issued regulations that apply to health plans and programs (referred to
herein as “health plan” or “health plans”) regarding the privacy of health information.
Understanding Your Health Record and Health Information
Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is
made. Typically, this record contains your symptoms, examination and test results, diagnoses,
treatment, and a plan for future care or treatment. This information serves as (i) a basis for
planning your care and treatment, (ii) a means of communication among health professionals
who contribute to your care, (iii) a legal document describing the care you received and a means
by which you or a third-party payer can verify that services billed were actually provided, (iv) a
source of data for medical research, (v) a source of information for public health officials, and
(vi) a tool by which U.S. Bank can assess and work to improve the U.S. Bank health programs.
Understanding what is in your record and how your health information is used helps you to
ensure its accuracy, better understand who, what, when, where, and why others may access your
health information and will help you make more informed decisions when authorizing disclosure
to others.
Your Health Information Rights
Although the U.S. Bank health programs have the right to use your health information in the
administration of the Program, the information belongs to you. You have the right, upon
submitting a written request, (i) to request a restriction on certain uses and disclosures of your
information, (ii) to receive confidential communication by alternative means or at alternative
locations if disclosure of the information could endanger you, (iii) to inspect and copy your
protected health information, (iv) to amend your protected health information, (v) to receive a
paper copy of this request, (vi) to obtain an accounting of the disclosures of your private health
information, and (vii) to revoke your authorization to use or disclose health information except to
the extent that the information has already been used or disclosed. To submit a written request,
send the request to:
U.S. Bank – EP-MN-R2BN
Benefits Administration
4000 W. Broadway
Robbinsdale, MN 55422-2299
U.S. Bank is not required to agree to any restriction that you request on your health information.
In addition, U.S. Bank may notify you that it is unable to communicate your health information
by alternative means or at alternative locations that you request.
Responsibilities of U.S. Bank
The Program is required to maintain the privacy of your health information, including electronic
health information, and to provide you with a notice as to the legal duties and privacy practices
with respect to information that the Program collects and maintains about you. Administrative,
physical and technical safeguards have been implemented to protect the confidentiality, integrity
and availability of health information.
The Ability of U.S. Bank to Change Its Practices
The Program reserves the right to amend or change their practices and to make the new
provisions effective for all protected health information maintained by the health programs.
Should the practices change, the Program will provide you with a revised notice. This
communication or revised notice will be provided to you either (i) through the U.S. mail,
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Retiree Health Care SPD Effective January 1, 2012
(ii) through inter-office mail or other internal distribution, (iii) through electronic communication
(such as e-mail or on an intranet), or (iv) along with your paycheck. The Program will not use or
disclose your health information without your authorization, except as described in the notice
that then applies to the health programs, and will abide by the terms of the notice currently in
effect.
Examples of Disclosures for Treatment, Payment, and Health Operations
The Program will use your health information for authorizing treatment. For example: The health
program requires a preauthorization for treatment by the health program or a third party
administrator, and you request pre-service authorization. The Program or a third party
administrator may consider your health information to determine whether to authorize the
treatment.
The Program will use your health information for payment. For example: A health program or a
third party administrator may receive a bill requesting payment for health care services provided
to you. The information on or accompanying the bill may include information that identifies you,
as well as your diagnosis, procedures, and supplies used that will be used by the Program or third
party administrator in making any payments on the bill.
The Program will use your health information for regular health operations. For example: A
health program or a third party administrator may receive a claim for benefits from you. The
information contained in the claim, accompanying the claim, or subsequently submitted as part
of the claim process may be used by the health program or third party administrator in deciding
your claim.
Examples of Uses of Health Information by U.S. Bank
The Program may use or disclose your private health information for any of the following
purposes:
• Business Associates: The Program may disclose health information to business associates,
with whom U.S. Bank or the Program contract for services. When the health programs
contract for these services, the health programs may disclose your health information to the
business associate so that they can perform their jobs. To protect your health information, the
Program requires the business associate to appropriately safeguard your information.
• Claims Processing: The Program may use or disclose health information to process payment
claims for health care services.
• Claims Review: The Program may use or disclose health information relevant to that
person’s involvement in your care or payment related to your care.
• Communication with Your Family: The Program may disclose to a family member, other
relative, close personal friend or any other person you identify, health information relevant to
that person’s involvement in your care or payment related to your care.
• Court Orders: The Program may disclose health information as required under a court
order.
• Education: The Program may use health information to contact you about treatment
alternatives or other health-related benefits and services that may be of interest to you.
• Employee Assistance Program: If U.S. Bank maintains or establishes an employee
assistance program, the Program may use or disclose health information you provide when
you contact the employee assistance program as provided under the terms and operation of
that program.
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Retiree Health Care SPD Effective January 1, 2012
• Federal, State, and Local Governmental Agencies: The Program may disclose health
information to federal, state and local governmental agencies as required under law.
• Funeral Directors: The Program may use or disclose health information to funeral directors
consistent with applicable law to carry out their duties.
• Health Program Design: The Program may use or disclose de-identified or aggregated
health information to U.S. Bancorp, the plan sponsor, business associates, and providers in
the health care and record keeping fields to assist U.S. Bank in the design and changes to the
design of its Program. U.S. Bank will not have any individually identifiable health
information for this purpose.
• Health Program Provider Selection: The Program may use or disclose health information
to business associates, and providers in the health care and record keeping fields to assist in
the selection of health program providers and to solicit bids from those entities.
• Law Enforcement: The Program may disclose health information for law enforcement
purposes as required by law or in response to a valid subpoena.
• Notification: The Program may use or disclose health information to notify or assist in
notifying a family member, personal representative, or another person responsible for your
care, your location, and general condition.
• Organ Donation: The Program may disclose health information to organ donation
organizations and to related entities that facilitate organ donations and transplants.
• Public Health: The Program may disclose health information to public health or legal
authorities charged with preventing or controlling disease, injury, or disability.
• Threats: The Program may, consistent with applicable law and ethics, disclose health
information to lessen a serious and imminent threat to the health or safety of a person or
persons to lessen that threat.
• Workers’ Compensation: The Program may use or disclose health information to the extent
authorized by and to the extent necessary to comply with laws relating to workers’
compensation or other similar programs established by law.
Additional Uses of Health Information by U.S. Bank
U.S. Bank may amend or change the list of uses of health information from time to time. When
U.S. Bank amends or changes the list of uses, it will inform you of the change. Other uses and
disclosures not on this list (or the list as subsequently amended) require your written
authorization. You may revoke your authorization for such other uses by submitting a written
request to revoke your authorization. This revocation is not effective with respect to any action
already taken by the Program in reliance on the authorization.
For More Information or to Report a Problem
If you have questions or would like additional information, including a copy of the HIPAA
Privacy Notice, you may contact the U.S. Bank Employee Service Center at 1-800-806-7009 or
send your written request to:
U.S. Bank – EP-MN-R2BN
Benefits Administration
4000 West Broadway
Robbinsdale, MN 55422-2299
If you believe your privacy rights have been violated, you can file a complaint with the Human
Resources Department or with the Secretary of Health and Human Services. You can file a
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Retiree Health Care SPD Effective January 1, 2012
complaint with the Human Resources Department at the address listed above. There will be no
retaliation for filing a complaint.
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Retiree Health Care SPD Effective January 1, 2012
GLOSSARY OF TERMS
Admission
Inpatient stay (in bed) that lasts at least one day and night.
Allergy Services
Medical services that involve evaluation and management of immune system disorders.
Allowed Amounts
The amount that is the basis for payment with regard to a given covered service. All benefit
payments under the BCBS administered options are based on the allowed amount. The allowed
amount may vary from one provider to another for the same service. Also, the Claims
Administrator may periodically adjust the allowed amount.
Medco uses the amount a participating pharmacy would charge if you showed your Medco ID
card. The BCBS allowed amount is the negotiated amount of payment that a participating
provider has agreed to accept as payment in full (less deductibles, coinsurance and copayments)
for a covered service at the time your claim is processed. The allowed amount may be based on
an estimated final price (including anticipated adjustments), or it may be based on discounts
from billed charges. See the “Allowed Amounts” section in this SPD for more information about
the determination of allowed amounts by BCBS.
Annual Maximum
The cumulative maximum amount payable by the U.S. Bank Retiree Health Care Program for a
particular covered medical service or prescription drug incurred by you during each plan year or
by each of your covered dependents during the plan year. The maximum does not include
amounts that are your responsibility (deductibles, coinsurance, copayments, penalties and other
amounts). Refer to the “What the Options Cover” section in this SPD for specific annual
maximums on certain medical services. For annual maximums related to prescription drugs, if
any, see the “Pharmacy” section in this SPD.
Average Semiprivate Room Rate
The average rate charged for a room with more than one bed. If the provider has no semiprivate
rooms, the program still uses the average semiprivate room rate for payment of the claim.
Claims Administrator
For the self-funded benefit options, U.S. Bank has delegated authority to several third party
claims administrators ("Claims Administrator") to interpret and construe the terms of the
Program and to determine all factual and legal questions under the Program with respect to all
initial claims for benefits and requests for review of adverse benefit determinations. This
delegated authority includes, but is not limited to, determinations of entitlement to benefits and
the amounts of the benefits to be paid. Your location and the coverage option you choose will
determine your specific Claims Administrator. For a list of Claims Administrators, see the
“Claims Administrator Information” section in this SPD.
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Retiree Health Care SPD Effective January 1, 2012
COBRA
COBRA is an acronym for Consolidated Omnibus Budget Reconciliation Act. Under COBRA,
employers have an obligation to make available to covered employees and their covered
dependents or eligible covered dependents of retirees, the continuation of certain benefits for a
period following the termination of the employment relationship or the occurrence of certain
other qualifying events, if they result in loss of coverage.
Coinsurance
A percentage of the cost of a service that you pay for eligible expenses once the deductible has
been satisfied. See the “Deductibles, Coinsurance and Maximums” section and in the “Pharmacy
Deductibles, Coinsurance and Maximums” section in this SPD for more information.
Copayment
Copayments are payments you make on a per-service basis for eligible expenses after the
deductible has been satisfied. See “Copayments” in the “Deductibles, Coinsurance and
Maximums” section and in the “Pharmacy Deductibles, Coinsurance and Maximums” section in
this SPD for more information.
Covered Service
A health service or supply that is eligible for benefits when performed and billed by an eligible
provider. You incur a charge on the date you receive a service, order a supply, or purchase a
drug.
Custodial Care
Services for the primary purpose of meeting personal needs. Services can be provided by persons
without professional skills or training. Custodial care does not include skilled care. Custodial
care includes giving medicine that can usually be taken without help, preparing special foods, or
helping someone to walk, get in and out of bed, dress, eat, bathe or use the toilet. The Program
does not cover custodial care.
Deductible
The per plan year amount you must pay toward eligible expenses before you and the health care
Program begin to share covered expenses. See “Embedded” and “Non-Embedded” in this
glossary and the “Deductibles, Coinsurance and Maximums” section in this SPD for more
information.
Durable Medical Equipment (DME)
Equipment that is medically necessary, able to withstand repeated use, used primarily for a
medical purpose, useful only to a person who is ill, appropriate for use in the patient's home and
prescribed by a physician. Durable medical equipment does not include such things as hot tubs,
whirlpool baths, vehicle lifts, waterbeds, air conditioners or purifiers, heat appliances,
dehumidifiers, computers or exercise equipment.
East Employee
East Employee designates those individuals who were:
• employed by Firstar Corporation, Mercantile Bancorporation, Inc. or Star Bank Corporation
before February 27, 2001; or
• employed before January 1, 2002, and who are classified on the payroll system as East
Region employees; or
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Retiree Health Care SPD Effective January 1, 2012
• covered under a retirement plan sponsored by Firstar Corporation before January 1, 2002.
Embedded
Something that is enclosed within something else. For example, the per person deductible and
out-of-pocket maximum amount is within the family deductible and out-of-pocket maximum
amount for the Comprehensive option. This allows each covered family member the opportunity
to get his/her eligible expenses covered prior to the entire family amount being met if you elect
family coverage.
Emergency
A critical condition that starts suddenly and requires immediate treatment to preserve or stabilize
your life, limb(s), eye(s) or health.
Explanation of Benefits (EOB)
The statement sent from the medical Claims Administrator following your receipt of a medical
service and a subsequent claim being filed. The EOB shows information about the service and
the associated charges, any provider reduction, the amount paid by the plan (if any), and the
amount that you are responsible to pay (if any). For pharmacy, the statement sent by Medco upon
completion of processing a submitted paper claim. When ordering prescriptions through Medco
Pharmacy (Medco’s mail order service), a statement is included with the prescription order and
is known as the Medco by Mail Pharmacy Statement.
Experimental, Investigative or Unproven
A drug, device, diagnostic test, medical treatment or procedure will be considered by the Claims
Administrator (or any person or third party to whom it delegates authority) to be experimental,
investigative or unproven if any of the following are true:
• If, at the time the drug, device, diagnostic test, medical treatment, or procedure is
furnished or proposed, it has not been approved for use by the appropriate governmental
agency (e.g., U.S. Food and Drug Administration) and such approval is required.
• If reliable evidence shows that the drug, device, diagnostic test, medical treatment or
procedure is not generally or commonly or customarily recognized by the medical
profession as appropriate and of scientifically proven value for the diagnosed illness or
injury at the particular presenting stage, and/or that further studies or clinical trials are
necessary to determine the maximum tolerated dose, toxicity, efficacy, or efficacy as
compared with standard means of diagnosis or treatment.
• If reliable evidence demonstrates that the drug, device, diagnostic test, medical treatment
or procedure is the subject of ongoing Phase I, II, or III clinical trials as follows:
− Phase I clinical trials determine the gate dosages of medication for Phase II trials and
define acute effects on normal tissue.
− Phase II clinical trials determine clinical response in a defined patient setting. If
significant activity is observed in any disease during Phase II, further clinical trials
usually study a comparison of the experimental treatment with the standard treatment
in Phase III trials.
− Phase III trials are typically quite large and require many patients to determine if a
treatment improves outcomes in a large population of patients.
If a drug, device, diagnostic test, medical treatment or procedure is so new, or its use for the
patient's condition is so new, that there is no reliable evidence nor published opinions by national
medical associations or other medical assessment groups, including, but not limited to, the
American Medical Association, the Food and Drug Administration, the Department of Health
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Retiree Health Care SPD Effective January 1, 2012
and Human Services, the National Institutes of Health, the Council of Medical Specialty
Societies and any other association or federal program or agency that has the authority to
approve medical testing and treatment, on which to base a scientific opinion of the medical value
of the proposed treatment.
For purposes of determining whether a drug, device, diagnostic test, medical treatment or
procedure is “experimental, investigative or unproven,” reliable evidence shall mean only
published reports and articles in the authoritative medical and scientific literature, written
protocol or protocols used by the treating provider or facility or another provider or other facility
studying substantially the same drug, device, diagnostic test, medical treatment or procedure
guidelines established by BCBS of MN Medical Policy Committee or the written informed
consent used by the treating provider or facility or by another provider or facility studying the
same drug, device, diagnostic test, medical treatment or procedure.
Family Practice
A branch of medicine that involves comprehensive health care for the entire family, including
obstetric care and minor surgical procedures.
Formulary
A list of commonly prescribed brand-name and generic drugs that Medco has designated as
“preferred” based on the drug’s clinical effectiveness and opportunities to help contain costs.
You receive the highest level of coverage when you use formulary (preferred) drugs.
HIPAA
HIPAA, which is an acronym for the Health Insurance Portability and Accountability Act, is a
federal law that was passed in 1996. HIPAA provides for portability of health care in certain
situations, such as by limiting pre-existing condition exclusions and providing for special
enrollment rights in group health plans. HIPAA also has provisions to protect the privacy of
patient medical records.
Home Health Care Agency
A provider that is licensed or certified as a home health care agency and sends health
professionals and home health aides into a home to provide health services.
Home Infusion Therapy
Treatment provided in the home by a home health care agency involving the administration of
nutrients, antibiotics and other drugs and fluids intravenously.
Hospice Care
Care for terminally ill patients that are no longer receiving treatment to cure their disease, with
the purpose of keeping them comfortable. An interdisciplinary team of professionals directs care,
with family members or friends acting as primary caregivers.
Hospital
A facility licensed or regulated as an acute care facility and staffed by physicians. Hospitals
provide inpatient and outpatient care 24 hours a day.
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Retiree Health Care SPD Effective January 1, 2012
In-Network Provider
For the Early Retiree Medical option, a provider who has entered into a service agreement with
the medical Claims Administrator for the network associated with your location and health care
option. If you receive services from an in-network provider, your expenses are generally covered
at a higher level than if you chose an out-of-network provider and you will not be responsible for
paying the difference between the billed charge and the allowed amount. Refer to the “Which
Network Providers to Use” section of this SPD for more information on the provider networks.
Lifetime Maximum
The cumulative maximum amount payable by the Program for a particular non-essential covered
medical service or prescription drug incurred by you during your lifetime or by each of your
covered dependents during the dependent's lifetime under all U.S. Bank Health Care Plans. The
maximum does not include amounts that are your responsibility (deductibles, coinsurance,
copayments, penalties and other amounts). Exceeding the lifetime maximum does not cause you
or your dependents to be eligible for any conversion right provided by the program. Refer to the
“What the Options Cover” section in this SPD for specific lifetime maximums on certain
services. For lifetime maximums related to prescription drugs, see the “Pharmacy” section in this
SPD.
Medical Supply
Supplies prescribed by a physician as medically necessary for treatment of an illness or injury.
Examples include casts, splints, trusses, braces or crutches, blood or blood plasma and
prosthetics. Medical supplies are not reusable and usually last less than one year.
Medically Necessary
A health care service, treatment or supply furnished by a particular provider is considered
medically necessary if, in the judgment of the Claims Administrator (or any person or third party
to whom it delegates authority), it is appropriate for and consistent with the diagnosis, care or
treatment of the illness or injury and:
• it is in accordance with generally accepted medical standards and good medical practice
(e.g., recognized by the American Medical Association) and requires the technical skills
of a medical, mental health or dental professional;
• it is indicated by the health status of the patient and is as likely to produce a significant
positive outcome, and no more likely to produce a negative outcome, as any alternative
service or supply;
• omitting it would adversely affect the patient's condition or the quality of medical care
rendered;
• it is the most appropriate level of service or treatment (for example, hospital inpatient
care that could not be provided appropriately on an outpatient basis);
• it is not furnished solely because the person is an inpatient, when the disease or injury
could safely and adequately be diagnosed or treated on an outpatient basis;
• it is not solely for the convenience of the patient or the physician, hospital or other
provider; and
• it is no more costly than any alternative service or supply that meets the above criteria.
Relevant information that will be taken into account when determining if a health care service,
treatment or supply is appropriate includes:
• information provided about the patient's health status;
• guidelines established by the BCBS Medical Policy Committee;
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Retiree Health Care SPD Effective January 1, 2012
• reports in peer-reviewed medical literature;
• reports and guidelines, including supporting scientific data, published by nationally
recognized health care organizations;
• generally recognized (in the United States) professional standards of safety and
effectiveness for diagnosis, care or treatment; and
• the opinions of health professionals in the generally recognized health specialty involved.
Generally, BCBS of MN makes medical necessity determinations. However, in certain locations,
medical necessity determinations may be made by the local BCBS plan.
Mental Health
As defined in the International Classification of Diseases. It does not include alcohol or drug
dependence, recreational abuse of drugs or mental retardation.
Non-Embedded
Something that is not enclosed within something else. For example, the per person deductible
and out-of-pocket maximum amount is not within the family deductible and out-of-pocket
maximum amount for the Early Retiree Medical option. The entire family amount must be met if
you elect family coverage. It can be met by one covered family member or by a combination of
covered family members.
Non-Participating Provider
For the Comprehensive option, a provider that has not entered into any service agreement with
the Claims Administrator. If you receive services from a non-participating provider, your
expenses are generally covered at a lower level than if you chose a participating provider and
you will be responsible for paying the difference between the billed charge and the allowed
amount. Refer to the “Which Network Providers to Use” section of this SPD for more
information on the provider network.
Non-Preventive Service/Non-Routine Care
A service that is performed on a regular basis to monitor health as a result of medical or family
history or is associated with an injury or illness.
Out-of-Network Provider
For the Early Retiree Medical option, a provider who has a service agreement with BCBS, but
not for the network associated with your location and health care option. If you receive services
from an out-of-network provider, your expenses are generally covered at a lower level than if
you chose an in-network provider and in most cases, you will not be responsible for paying the
difference between the billed charged and the allowed amount. Refer to the “Which Network
Providers to Use” section of this SPD for more information on the provider networks.
Out-of-Pocket Maximum
The per plan year limit you must pay toward eligible expenses before any additional eligible
services you incur are paid by the health care option at 100% of the allowed amount for the
remainder of the year (as long as any applicable annual or lifetime maximums have not been
exceeded). See “Embedded” and “Non-Embedded” in this glossary and the “Deductibles,
Coinsurance and Maximums” section in this SPD for more information.
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Retiree Health Care SPD Effective January 1, 2012
Participating Provider
For the Comprehensive option, a provider that has entered into a service agreement with BCBS.
If you receive services from a participating provider, your expenses are generally covered at a
higher level than if you had chosen a non-participating provider and you will not be responsible
for paying the difference between the billed charge and the allowed amount. Refer to the “Which
Network Providers to Use” section of this SPD for more information on the provider networks.
Pharmacy Deductible
The annual amount you must pay toward eligible prescription drug purchases or prescribed
supplies received at a pharmacy each year before benefits are paid on your behalf.
Pharmacy Out-of-Pocket Maximum
For the Comprehensive, UnitedHealthcare and Medica options the dollar amount you pay
(deductible plus coinsurance) toward prescription drug purchases or prescribed supplies in a year
before the Program will pay 100% of the allowed amount for any additional eligible drugs or
supplies you incur for the rest of that year, as long as any annual or lifetime maximums have not
been exceeded. See Out-of-Pocket Maximum in the “Pharmacy” section earlier in this SPD for
more information.
Plan Year
January 1 through December 31.
Preferred Provider Organization (PPO) Plan
A Preferred Provider Organization (PPO) is a plan that uses a network of medical care providers
that have agreed to provide various health care services for specified fees. You are generally
required to use a provider who is participating in the PPO network. You do not need to select a
primary care physician and you do not need a referral to other PPO network providers.
Premium
For insured benefits (Kaiser Colorado, Medica and UnitedHealthcare), the amount of money a
policyholder agrees to pay an insurance company for an insurance policy, in return for which the
insurance company provides payment of specified benefits. For self-insured benefits (BCBS of
MN), your contribution to the total cost of medical and pharmacy expenses paid by the plan and
is billed monthly.
Prescription Drugs
Drugs, including insulin, that are required by state or federal law to be dispensed only by
prescription of a health professional who is authorized by law to prescribe the drug. Medco
maintains listings of brand-name and generic drugs, called formulary (preferred) drugs.
Preventative Service
Generally, a routine service that promotes good health, is performed on a regular basis, not as a
result of your medical or family history, or associated with an injury or illness.
Provider
For health care plans, any individual, institution or agency that provides health services to health
care consumers.
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Retiree Health Care SPD Effective January 1, 2012
Skilled Care
Services that are medically necessary and must be provided by licensed nurses or other providers
eligible to develop, provide, and evaluate care. Custodial care and services of a non-medical
nature are specifically not included. Care is not considered skilled merely because it is provided
by or under the direct supervision of a licensed nurse. Where care or services can be safely and
effectively provided by a non-medical person without the direct supervision of a licensed nurse,
the care shall not be regarded as skilled care whether or not a skilled nurse actually provides the
service.
Specialist
A doctor with a concentration of training in a specific branch of medicine.
Substance Abuse
Alcohol or drug dependence as defined in the most recent edition of International Classification
of Diseases.
Summary Plan Description (SPD)
A document – this document – that provides comprehensive information about a given benefit,
including eligibility provisions, coverage options and details, and claims procedures.
Temporomandibular Joint (TMJ)
The connecting hinge between the lower jaw (mandible) and the base of the skull (temporal
bone).
U.S. Bank Employee Service Center
The U.S. Bank interactive voice response (IVR) system, which is available 24 hours a day, seven
days a week via touch-tone phone at 1-800-806-7009. The U.S. Bank Employee Service Center
enables you to get answers to most questions and complete transactions without the aid of a
representative. However, if you need assistance, representatives are available Monday through
Friday, 8 a.m. to 8 p.m. CT, excluding holidays.
West Employee
West Employee designates those individuals who were:
• employed by U.S. Bank or U.S. Bancorp before February 27, 2001;
• employed before January 1, 2002, and who are classified in the payroll as West Region
employees; or
• covered under the U.S. Bancorp Retiree Health Care Program before January 1, 2002.
Years of Service
For purposes of the U.S. Bank Retiree Health Care Program, a Year of Service is defined in the
same manner as used to determine vesting service under the U.S. Bank Pension Plan; except that
for purposes of determining eligibility to participate in the Program (but not for purposes of
calculating Retiree Health Care Credits) if you are involuntarily terminated, any period of time
that you are enrolled in subsidized health care benefits will count for purposes of calculating a
Year of Service. Except as specifically noted with respect to the inclusion of the period of time
that you receive subsidized health care benefits when involuntarily terminated, for purposes of
calculating a Year of Service, all of the other requirements of the U.S. Bank Pension Plan will
apply. To have a Year of Service, you must work at least “1,000 hours of service,” as determined
under the rules of the Pension Plan (including any subsequent changes to the Pension Plan). In
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Retiree Health Care SPD Effective January 1, 2012
any year that you are employed but do not have a Year of Service (for example a year in which
you work less than 1,000 hours), you will not get any credit toward the Retiree Health Care
Program for any purpose. Any year in which you do not have a Year of Service will not count
toward the required five Years of Service for participation in the Retiree Health Care Program.
If you previously worked for an entity acquired by U.S. Bank, your Years of Service toward the
Program will include prior service with the acquired entity to the extent the prior service is
credited for purposes of the U.S. Bank Pension Plan.
If you leave and return to work with U.S. Bank, the “Break in Service” rules from the U.S. Bank
Pension Plan will determine whether service predating the break continues to count as a Year of
Service under the Program.
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Retiree Health Care SPD Effective January 1, 2012
IMPORTANT RESOURCES
If, after reviewing this SPD, you have a question or need assistance, call the U.S. Bank Employee
Service Center. If you have specific questions about what an option covers, contact the applicable claims
administrator. U.S. Bank contracts with these carriers to provide administrative services.
U.S. Bank Employee Service Center
General number: 1-800-806-7009
Representatives are available Monday through Friday (except
holidays), 8 a.m. to 8 p.m. CT. The Web site is available 24
www.yourbenefitsresources.com/usbank
hours a day Monday – Saturday and after 12 p.m. CST on
Sunday.
U.S. Bank Employee Service Center
P.O. Box 785080
Orlando, FL 32878-5080
Blue Cross and Blue Shield of Minnesota
Group Number: Check your BCBS ID card.
Twin Cities Metro Area
651 662-5550
Outside Twin Cities Metro Area
1-800-729-3039
TDD* Twin Cities Metro Area
651-662-8700
TDD* Outside Twin Cities Area
1-888-878-0137
BlueCard Access (for assistance locating network providers
after business hours, available 24 hours a day, seven days a
week)
Kaiser Colorado
Medco
Prescription drug provider for medical options administered by
Blue Cross and Blue Shield of Minnesota, UnitedHealthcare and
Medica
Group Number: USBANK1
Medica-Center for Healthy Aging
Customer Service
TTY
Group Nos.:
Plan 1 – 70833
Plan 2 – 70835
152
www.bluecrossmn.com/usb
BCBS of Minnesota
U.S. Bank Dedicated Service Center
3535 Blue Cross Road, Rte. P1-2
St. Paul, MN 55122
800-810-BLUE (800-810-2583)
303-338-3800 or 1-800-632-9700
www.kaiserpermanente.org
http://my.kaiserpermanente.org/usbank
General number: 1-800-864-1404
TDD:* 1-800-759-1089
www.medco.com
952-992-2345 or 1-800-906-5432
952-992-3650 or 1-800-234-8819
8 a.m. to 8 p.m., central time
Monday through Sunday
Medica Insurance Company
P.O. Box 9310
Minneapolis, MN 55440-9745

Retiree Health Care SPD Effective January 1, 2012
UnitedHealthcare® Group Medicare Advantage PPO
Pre enrollment number
Customer Service Department
Group Nos.
Plan 1 UnitedHealthcare PPO 68089
Plan 2 UnitedHealthcarePPO 68090
* Telecommunications Device for the Deaf
153
1-877-714-0178
TTY 711
8 a.m. to 8 p.m. local time, 7 days a week
1-800-457-8506
TTY 711
8 a.m. to 8 p.m., local time, 7 days a week
UnitedHealthcare
P.O. Box 29650
Hot Springs, AR 71903-9973

Retiree Health Care SPD Effective January 1, 2012
APPENDIX
ELIGIBILITY AND ENROLLMENT
The eligibility and enrollment rules for the U.S. Bank Retiree Health Care Program (the
Program) differ based upon your date of retirement and your employee status at the time of
retirement. This appendix contains three separate sections describing the various eligibility and
enrollment requirements that were in effect prior to January 1, 2012.
The following chart identifies the eligibility and enrollment section that applied to you based
upon your retirement date and employee status at the time of retirement.
Eligibility & Enrollment Rules Eligibility & Enrollment Rules Eligibility & Enrollment Rules
Section A
Section B
Section C
All U.S. Bank employees who West Employees* who retired East Employees** who retired
retire on or after January 1, 2003. before January 1, 2002.
before January 1, 2002.
West Employees* who retired or West Employees* who retired Employees formerly employed
whose LTD or severance period between January 1, 2002 and by Mercantile Bancorporation
began between January 1, 2002 December 31, 2002 and who who retired before January 1,
and December 31, 2002 and who
elected the health care credits
option.
elected the fixed subsidy option. 2003.
West Employees* who retired or West Employees* whose LTD or Employees formerly employed
whose LTD or severance period severance period began before by Mercantile Bancorporation
began between January 1, 2002 January 1, 2002.
whose LTD or severance period
and December 31, 2002 and who
were not entitled to the fixed
subsidy option.
began before January 1, 2003.
East Employees** who retired or West Employees* who retired or
whose LTD or severance period whose LTD or severance period
began on or after January 1, 2002 began between January 1, 2002
(not including employees and December 31, 2002 and who
formerly employed by Mercantile
Bancorporation).
elected the fixed subsidy option.
* West Employees are those individuals who were:
• employed by U.S. Bank or U.S. Bancorp before February 27, 2001;
• employed before January 1, 2002 and who are classified in the payroll system as West Region employees; or
• covered under the U.S. Bancorp Retiree Health Care Program before January 1, 2002.
** East Employees are those individuals who were:
• employed by Firstar Corporation, Mercantile Bancorporation, Inc., or Star Bank Corporation before
February 27, 2001; or
• employed before January 1, 2002 and who are classified on the payroll system as East Region employees; or
• covered under a retirement plan sponsored by Firstar Corporation before January 1, 2002.
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Retiree Health Care SPD Effective January 1, 2012
Eligibility and Enrollment Rules Section A
This eligibility and enrollment section only applies to:
• Employees who retire/terminate on or after January 1, 2003;
• West Employees who retired or whose LTD or severance period began between January 1,
2002, and December 31, 2002, and who elected the health care credits option;
• West Employees who retired or whose LTD or severance period began between January 1,
2002, and December 31, 2002, and who were not entitled to the fixed subsidy option; and
• East Employees who retired or whose LTD or severance period began on or after January 1,
2002 (not including employees formerly employed by Mercantile Bancorporation).
Retiree Eligibility
You are eligible to participate in the Program if:
• you are age 55 or older at the time of your termination, or if you are involuntarily terminated,
the date that your subsidized health care benefits end;
• you have five or more Years of Service as determined under the terms of the U.S. Bank
Pension Plan; except if you are involuntarily terminated, any period of time that you are
enrolled in subsidized health care benefits will count for purposes of calculating a Year of
Service (refer to the “Glossary of Terms” section of this SPD for the definition of Years of
Service);
• you retire from U.S. Bank; and
• you are eligible for and enrolled in a U.S. Bank active employee health care option as of your
termination.
You are not a participant in the Program until you have satisfied all the eligibility requirements
listed above. While certain employees may accumulate retiree health credits while still
employed, the accumulation of these credits does not make employees participants in the
Program.
Note: If you are not eligible for and covered under a U.S. Bank active employee health care
option immediately before your termination, you will not be eligible to participate in the
Program, even if you have accumulated retiree health care credits while employed.
Dependent Eligibility
For those retirees enrolled in the Kaiser option, Kaiser provided materials regarding
dependent eligibility.
“Eligible dependents” for the purposes of U.S. Bank benefits are listed below. You will need to
provide your dependent’s Social Security number (SSN) when adding or enrolling a dependent.
Refer to “Dependent Data Requirement” in this SPD for further information about this
requirement. In addition, U.S. Bank and its designated administrators may request proof of
dependent eligibility at any time. Failure to provide such proof may result in termination of
coverage.
Your dependent(s) will be eligible to participate in the Program, if:
• your dependent was covered by your U.S. Bank active employee health care option at the
time of your termination;
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Retiree Health Care SPD Effective January 1, 2012
• you are eligible to participate in the Program and you enroll yourself and your eligible
dependent at the time of your termination; and
• your dependent continues to satisfy one of the following requirements:
• Your spouse/domestic partner* (unless legally separated from you). Under the federal
Defense of Marriage Act (DOMA), a spouse is a husband or wife of opposite sex. A
common-law spouse may be covered only if you reside in a state that recognizes
common-law marriage and you meet the common-law requirements at the time you enroll
the dependent in coverage. To enroll a domestic partner in coverage, you must meet the
eligibility criteria defined under “Domestic Partner Eligibility” section in this SPD.
• You or your domestic partner’s children/grandchildren under age 26** who are:
− Your/your domestic partner’s biological children;
− your stepchildren;
− your/your domestic partner’s foster children;
− children/grandchildren for whom you or your spouse/domestic partner have legal
guardianship***;
− children/grandchildren legally adopted by you or your spouse/domestic partner or
placed with you or your spouse/domestic partner for adoption***; and
− grandchildren who are eligible to be claimed as an exemption on you or your
spouse/domestic partner’s federal income tax return.
• Disabled children age 26 and older who otherwise meet the dependent children definition
may be covered as long as ALL of the following requirements are met:
– the child is severely disabled by prolonged physical or mental incapacity;
– the child became disabled prior to reaching age 26;
– the child was covered by the plan prior to reaching age 26, or, if older than age 26,
loses coverage under a parent’s/guardian’s plan. In the event of loss of coverage, proof of
prior coverage must be provided;
– the child is unmarried and you/your domestic partner provide more than 50% of his or
her support because he or she is unable to earn a living; and
– disabled dependent status is approved by a medical Claims Administrator for
U.S. Bank.
To have the disabled child considered for coverage, you and his or her doctor must
complete an application form for the child. The form is available from the applicable
medical Claims Administrator. To be considered, the form must be received by the
medical Claims Administrator no later than 30 days after the date the child turns age 26.
See the “Important Resources” section of this SPD for telephone numbers for the medical
Claims Administrators. If coverage for the child is approved and the child is not
considered permanently disabled, periodically you will be asked to submit proof to the
medical Claims Administrator that the child continues to meet eligibility requirements.
Failure to provide requested information may result in loss of coverage for the dependent.
*Even though some localities may recognize same-sex marriages, the U.S. Bank Benefits Program is governed by
federal regulations which require that coverage for partners must be paid for on an after-tax basis, and the cost of
coverage be considered imputed income. Therefore, even in the event of marriage or civil union, if you are enrolling
your same-sex spouse you must designate him/her as a domestic partner.
** For health care coverage, a newborn is not considered a dependent until birth.
*** Documentation of legal guardianship or adoption is required. Please call the U.S. Bank Employee Service
Center for instructions. The dependent cannot be added to your coverage until a copy of the applicable documents
are received and verified by the U.S. Bank Employee Service Center.
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Retiree Health Care SPD Effective January 1, 2012
If your disabled dependent loses coverage under another health care plan, please contact
the U.S. Bank Employee Service Center for information regarding the procedure for
applying for coverage under the U.S. Bank Retiree Health Care Program.
Children who become disabled after age 26 are not eligible for coverage.
Ineligible Dependents. Ineligible dependents include, but are not limited to, the following:
• Dependents in the Military. Coverage is not available for any dependent on active duty in
the uniformed services or armed forces of any country.
• Dependent Parents. Coverage is not available for a retiree's or retiree's spouse's/domestic
partner’s parents.
• Former Spouses/Domestic Partners. A spouse from whom you are divorced (even if the
divorce decree stipulates you will continue health care, pharmacy care, dental care or vision
care coverage for your ex-spouse) or legally separated, or a domestic partner or domestic
partner’s dependents if your domestic partnership has ended.
• Spouse/Domestic Partner of Adult Children/Grandchildren. Coverage is not available for
an adult child’s or grandchild’s spouse/domestic partner.
Enrolling ineligible dependents is a violation of company policy and will be treated accordingly.
If U.S. Bank determines that an ineligible dependent has been enrolled, coverage will be
cancelled retroactively. U.S. Bank reserves the right to recover any and all benefit payments
made for services received by ineligible dependents.
For more information about eligibility, enrollment and coverage for domestic partners and
dependents of domestic partners, see the “Domestic Partner Eligibility” section of this SPD.
Enrollment Rules
You may initiate your enrollment into the Program up to 90 days prior to your termination date
by contacting the U.S. Bank Employee Service Center at 1-800-806-7009 or online at
www.yourbenefitsresources.com/usbank. If you are eligible to participate in the Program when
you terminate from U.S. Bank and have not enrolled prior to your termination date, you will
receive enrollment materials that specify an enrollment deadline. You must enroll yourself and
any eligible dependents by the deadline indicated on your election materials; otherwise you and
your dependents will not be covered by the Program.
Coverage Levels. For any of the health care options available to you, you can select from two
coverage levels:
• Individual (yourself - the retiree - only); or
• Family (you, and/or any eligible dependents as previously defined in this section).
Effective Date. If you elect coverage by your enrollment deadline, and are enrolling yourself
and/or your dependents in the Early Retiree Medical or Comprehensive options, coverage is
effective the first day of the month after the date your active employee health care ended or if
you are involuntarily terminated, coverage is effective the first day of the month after the date
your subsidized health care ends. For dependents covered with you as of the date of your
termination or the date your subsidized health care coverage ends, coverage will be effective the
same date as your coverage is effective, if you enroll them at the same time that you enroll. You
will be responsible for the retroactive premiums due for retiree coverage back to the effective
date of your retiree health care coverage.
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Retiree Health Care SPD Effective January 1, 2012
If you elect coverage by your enrollment deadline, and are enrolling yourself and/or your
dependents in the UnitedHealthcare or Medica Plan options, coverage is generally effective the
first day of the month after your application(s) is received and processed. If you will experience
a lapse in coverage between your termination of employment and your effective date of
coverage, you must call the U.S. Bank Employee Service Center at 1-800-806-7009. You will be
responsible for the premiums due for retiree coverage back to the effective date of your retiree
health care coverage.
Deciding Between Retiree Health Care Coverage and COBRA Health Care Coverage.
Separate from the Program enrollment information, you and any other covered dependents will
also receive information on continuing the health care coverage you were enrolled in as an active
employee under the provisions of COBRA. Each of your covered dependents will have an
independent right to decide whether to elect COBRA.
You and your covered dependents will need to decide whether to elect:
• Retiree Health Care Program coverage; or
• COBRA health care coverage.
By electing Retiree Health Care Program coverage, you will waive your COBRA health care
rights. You may, however, revoke such waiver at any time during the 60-day COBRA election
period.
If you elect COBRA health care rather than retiree health care coverage under the
Program, you will not have an option to enroll in the Program when you either stop or
exhaust your COBRA health care coverage.
It is important to carefully compare the benefits of COBRA health care versus retiree health care
coverage in making this decision. If you have questions about the two types of coverage, contact
the U.S. Bank Employee Service Center at 1-800-806-7009.
One-Time Option to Enroll in Retiree Program. There is a single point of entry into the
Program – at the time of your termination. This means that if you do not enroll yourself
and any eligible dependents in the Program by the enrollment deadline stated on your
enrollment worksheet, you will not be able to enroll yourself and/or your dependents in
retiree health care coverage at any time in the future.
If, for example, at the time you terminate, you elect COBRA health care or coverage under a
spouse’s/domestic partner’s plan or a new employer’s plan, instead of coverage under the
Program, you will not be able to enroll in the Program at the time your COBRA health care
continuation period or other coverage ends. Similarly, you must enroll any eligible dependents in
the Program at the time of your termination to retain their coverage. Therefore, if you and/or a
dependent want coverage under the Program at any point after your termination, you must enroll
them when you terminate. You may, however, have the right to add new dependents gained after
your termination. Refer to the “New Dependents Gained After Your Termination” section below
for more information.
New Dependents Gained After Your Termination. If you gain a dependent after you terminate
due to marriage, commencement of a domestic partnership, birth, adoption or commencement of
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Retiree Health Care SPD Effective January 1, 2012
a legal guardianship, your new dependent may be eligible for coverage under the Program if the
following requirements are met:
• You must enroll your new dependent within 60 days of the date they first become your
dependent after your termination; and
• Your new dependent continues to satisfy the requirements of an “eligible dependent”, as
defined in the “Dependent Eligibility” section.
If, however, one of your current dependents later gains eligibility due to a change in the
eligibility requirements, you will not be able to enroll that dependent in the Program.
To enroll a new dependent, call the U.S. Bank Employee Service Center at 1-800-806-7009 and
speak to a representative. If your new dependent is a domestic partner or dependent of a
domestic partner, see the “Domestic Partner Eligibility” section in this SPD.
If you are enrolling your dependent(s) in the Early Retiree Medical or Comprehensive option,
your benefit changes will be effective on the first day of the month following the date you
experience a qualifying new dependent enrollment event and contact the U.S. Bank Employee
Service Center to make your election unless:
• You are adding a newborn or newly adopted child (or a child newly placed with you for
adoption). If you are adding a newborn or newly adopted/placed for adoption child,
health care coverage for that dependent will be retroactive to the date of the event. If
coverage is retroactive, premiums will also be retroactive; or
• If your new dependent enrollment event occurs on the first of the month and you contact
the U.S. Bank Employee Service Center on that day, your coverage will become effective
on that day.
If you are enrolling your dependent(s) in the UnitedHealthcare or Medica Plan option, coverage
is generally effective the first day of the month after your application is received and processed,
or the first of the month following the date you experience a qualifying new dependent
enrollment event and contact the U.S. Bank Employee Service Center to make your election,
whichever is later.
Coverage Cancellation. You can cancel coverage for yourself and/or your dependents at any
time by calling the U.S. Bank Employee Service Center at 1-800-806-7009. If after electing
coverage when you terminate, you cancel or lose retiree health care coverage under the Program
for any reason (including non-payment of premiums), you will not be able to re-enroll in the
Program. If you cancel or lose retiree health care coverage, any covered dependents will also
lose coverage, subject under certain circumstances and rights to COBRA coverage.
Similarly, if you cancel coverage for an eligible dependent for any reason, that dependent will
not be able to re-enroll in the Program.
If you and/or your dependents are enrolled in the Early Retiree Medical or Comprehensive
option or the Kaiser option, the coverage cancellation effective date is the first of the month
following the date that you contact the U.S. Bank Employee Service Center to cancel coverage
unless you contact the U.S. Bank Employee Service Center on the first of the month, then your
coverage will be canceled on that day.
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Retiree Health Care SPD Effective January 1, 2012
If you and your dependents are enrolled in the UnitedHealthcare or Medica Plan option, the
coverage cancellation effective date is the first of the month following the date that the U.S.
Bank Employee Service Center receives a written request to disenroll you and/or your
dependents from the UnitedHealthcare or Medica Plan option. This request must be signed and
dated by each member that wants to disenroll from the UnitedHealthcare or Medica Plan option.
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Retiree Health Care SPD Effective January 1, 2012
Eligibility and Enrollment Rules Section B
This eligibility and enrollment section only applies to:
• West Employees who retired before January 1, 2002;
• West Employees who retired between January 1, 2002, and December 31, 2002, and who
elected the fixed subsidy option;
• West Employees whose LTD or severance period began before January 1, 2002; and
• West Employees who retired or whose LTD or severance period began between January 1,
2002, and December 31, 2002, and who elected the fixed subsidy option.
Retiree Eligibility
You are eligible to participate in the Program if:
• you are age 55 or older at the time of your termination, or if you are involuntarily terminated,
the date that your subsidized health care benefits end;
• you have five or more Years of Service as determined under the terms of the U.S. Bank
Pension Plan; except if you are involuntarily terminated, any period of time that you are
enrolled in subsidized health care benefits will count for purposes of calculating a Year of
Service (refer to the “Glossary of Terms” section of this SPD for the definition of Years of
Service);
• your age and Years of Service total at least 65; and
• you are eligible for and enrolled in a U.S. Bank active employee health care option at the
time of your termination.
Dependent Eligibility
Refer to the materials from Kaiser for information about dependent eligibility under this
option.
“Eligible dependents” for the purposes of U.S. Bank benefits are listed below. You will need to
provide your dependent’s Social Security number (SSN) when adding or enrolling a dependent.
Refer to “Dependent Data Requirement” in this SPD for further information about this
requirement. In addition, U.S. Bank and its designated administrators may request proof of
dependent eligibility at any time. Failure to provide such proof may result in termination of
coverage.
Your dependent(s) will be eligible to participate in the Program, if:
• your dependent was covered by your U.S. Bank active employee health care option at the
time of your termination; and
• your dependent continues to satisfy one of the following requirements except as noted:*
• Your spouse/domestic partner** (unless legally separated from you). Under the federal
Defense of Marriage Act (DOMA), a spouse is a husband or wife of opposite sex. A
common-law spouse may be covered only if you reside in a state that recognizes
common-law marriage and you meet the common-law requirements at the time you enroll
the dependent in coverage. To enroll a domestic partner in coverage, you must meet the
eligibility criteria defined under “Domestic Partner Eligibility” section in this SPD.
• You or your domestic partner’s children/grandchildren under age 26*** who are:
– your/your domestic partner’s biological children;
– your stepchildren;
– your/your domestic partner’s foster children;
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Retiree Health Care SPD Effective January 1, 2012
– children/grandchildren for whom you or your spouse/domestic partner have legal
guardianship;****;
– children/grandchildren legally adopted by you or your spouse/domestic partner or
placed with you or your spouse/domestic partner for adoption****; and
– grandchildren who are eligible to be claimed as an exemption on you or your
spouse/domestic partner’s federal income tax return.
• Disabled children age 26 and older who otherwise meet the dependent children definition
may be covered as long as ALL of the following requirements are met:
– the child is severely disabled by prolonged physical or mental incapacity;
– the child became disabled prior to reaching age 26;
– the child was covered by the plan prior to reaching age 26, or, if older than age 26,
loses coverage under a parent’s/guardian’s plan. In the event of loss of coverage, proof of
prior coverage must be provided;
– the child is unmarried and you/your domestic partner provide more than 50% of his or
her support because he or she is unable to earn a living; and
– disabled dependent status is approved by a medical Claims Administrator for U.S.
Bank.
* Domestic partners and/or dependents of domestic partners of West Employees who terminated before January 1,
2002, are not eligible for coverage under the Program.
**Even though some localities may recognize same-sex marriages, the U.S. Bank Benefits Program is governed by
federal regulations which require that coverage for partners must be paid for on an after-tax basis, and the cost of
coverage be considered imputed income. Therefore, even in the event of marriage or civil union, if you are enrolling
your same-sex spouse you must designate him/her as a domestic partner.
*** For health care coverage, a newborn is not considered a dependent until birth.
**** Documentation of legal guardianship or adoption is required. Please call the U.S. Bank Employee Service
Center for instructions. The dependent cannot be added to your coverage until a copy of the applicable documents
are received and verified by the U.S. Bank Employee Service Center.
To have the disabled child considered for coverage, you and his or her doctor must complete an
application form for the child. The form is available from the applicable medical Claims
Administrator. To be considered, the form must be received by the medical Claims
Administrator no later than 30 days after the date the child turns age 26. See the “Important
Resources” section of this SPD for telephone numbers for the medical Claims Administrators. If
the child is approved and the child is not considered permanently disabled, periodically you will
be asked to submit proof to the medical Claims Administrator that the child continues to meet
eligibility requirements. Failure to provide requested information may result in loss of coverage
for the dependent.
If your disabled dependent loses coverage under another health care plan, please contact the
U.S. Bank Employee Service Center for information regarding the procedure for applying for
coverage under the U.S. Bank Retiree Health Care Program.
Children who become disabled after age 26 are not eligible for coverage.
If you or any of your dependents were not enrolled in one of the U.S. Bank active employee
health care options as of your termination date, you may elect coverage in the future only if
you/they qualify for a Health Care Special Enrollment, as described in the “Later Enrollment
(Health Care Special Enrollment)” section.
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Retiree Health Care SPD Effective January 1, 2012
Ineligible Dependents. Ineligible dependents include, but are not limited to the following:
• Dependents in the Military. Coverage is not available for any dependent on active duty in
the uniformed services or armed forces of any country.
• Dependent Parents. Coverage is not available for a retiree's or retiree's spouse's/domestic
partner’s parents.
• Former Spouses/Domestic Partners. A spouse from whom you are divorced (even if the
divorce decree stipulates you will continue health care, pharmacy care, dental care or vision
care coverage for your ex-spouse) or legally separated, or a domestic partner or domestic
partner’s dependents if your domestic partnership has ended.
• Spouse/Domestic Partner of Adult Children/Grandchildren. Coverage is not available for
an adult child’s or grandchild’s spouse/domestic partner.
Enrolling ineligible dependents is a violation of company policy and will be treated accordingly.
If U.S. Bank determines that an ineligible dependent has been enrolled, coverage will be
cancelled retroactively. U.S. Bank reserves the right to recover any and all benefit payments
made for services received by ineligible dependents.
For more information about eligibility, enrollment and coverage for domestic partners and
dependents of domestic partners, see the “Domestic Partner Eligibility” section of this SPD.
Enrollment Rules
You may initiate your enrollment into the Program up to 90 days prior to your termination date
(or up to 90 days prior to the date your COBRA coverage ends if you continue coverage through
COBRA) by contacting the U.S. Bank Employee Service Center at 1-800-806-7009 or online at
www.yourbenefitsresources.com/usbank. If you are eligible to participate in the Program when
you terminate from U.S. Bank and have not enrolled prior to your termination date, you will
receive enrollment materials that specify an enrollment deadline. You must enroll yourself and
any eligible dependents by the deadline indicated on your election materials, (or within 60 days
from the date your COBRA coverage ends if you continue coverage through COBRA) otherwise
you will not be covered by the Program.
Note: If you do not enroll within the above timeframes, you will not be able to enroll at a later
date unless you qualify for a Health Care Special Enrollment. Dependents not covered with you
as of your termination date are not eligible for coverage unless they qualify for a Health Care
Special Enrollment.
Coverage Levels. For any of the health care options available to you, you can select from two
coverage levels:
• Individual (yourself — the retiree — only); or
• Family (you, and/or any eligible dependents as previously defined in this section).
Effective Date. If you elect coverage by your enrollment deadline or within 60 days of the date
your coverage ends under COBRA (if you elect COBRA at the time you terminate), and are
enrolling yourself and/or your dependents in the Early Retiree Medical or Comprehensive
option, coverage is effective the first day of the month after the date your active employee health
care ended or if you enrolled in COBRA coverage, coverage is effective the first day of the
month after the date your COBRA health care ended. For dependents covered with you as of the
date of your termination or the date your COBRA coverage ends, coverage will also be effective
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Retiree Health Care SPD Effective January 1, 2012
the date that your coverage is effective, if you enroll them at the same time that you enroll. You
will be responsible for the premiums due for retiree coverage back to the effective date of your
retiree health care coverage.
If you elect coverage by your enrollment deadline or within 60 days of the date your coverage
ends under COBRA (if you elect COBRA at the time you terminate), and are enrolling yourself
and/or your dependents in the UnitedHealthcare or Medica Plan option, coverage is generally
effective the first day of the month after your application(s) is received and processed. You will
be responsible for the premiums due for retiree coverage back to the effective date of your retiree
health care coverage.
Deciding Between Retiree Health Care Coverage and COBRA Health Care Coverage.
Separate from the Program enrollment information, you and any other covered dependents will
also receive information on continuing the health care coverage you were enrolled in as an active
employee under the provisions of COBRA. Each of your covered dependents will have an
independent right to decide whether to elect COBRA.
You and your covered dependents will need to decide whether to elect:
• Retiree Health Care Program coverage; or
• COBRA health care coverage and then enroll in the Retiree Health Care Program.
By electing Retiree Health Care Program coverage, you will waive your COBRA health care
rights. You may, however, revoke such waiver at any time during the 60-day COBRA election
period.
Special Enrollment Rights under CHIPRA
CHIPRA is an acronym for the Children’s Health Insurance Program Reauthorization Act of 2009 and
was signed into law on Feb. 9, 2009. It extends and expands the Children’s Health Insurance Program
(CHIP, formerly known as the State Children’s Health Insurance Program or SCHIP). CHIPRA provides
for the following:
• If you or your dependent’s Medicaid or CHIP coverage is terminated because you are no longer
eligible, you qualify for a Health Care Special Enrollment which will allow you to enroll in U.S.
Bank coverage.
• If you or your dependents become eligible for a premium assistance subsidy under Medicaid or CHIP,
you qualify for a Health Care Special Enrollment which will allow you to enroll in U.S. Bank
coverage.
Later Enrollment (Health Care Special Enrollment). To enroll yourself or an eligible
dependent after the deadline on your election materials, you or your eligible dependent must
qualify for a Health Care Special Enrollment. You may qualify for a Health Care Special
Enrollment if you have new dependents or you or a dependent loses existing health care
coverage through another source.
To request a Health Care Special Enrollment, you must contact the U.S. Bank Employee
Service Center and speak to a representative no later than 60 days after the date of your
Health Care Special Enrollment event. (A copy of the certificate or other official paperwork
showing the date of the event or proving loss of coverage may be required.)
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Retiree Health Care SPD Effective January 1, 2012
Coverage, other than for Children under age 19, newly adopted children or children newly placed
for adoption, may be subject to a pre-existing conditions limitation.
A Health Care Special Enrollment is available only to retirees to whom this Section B applies
and who:
• previously qualified for the U.S. Bank Retiree Health Care Program;
• declined participation when initially eligible because of other health coverage; and
• have now lost the other coverage.
Events that may qualify for a Health Care Special Enrollment include the following situations:
• loss of other coverage* for reasons such as:
– divorce, legal separation, annulment or termination of domestic partnership;
– death;
– termination of employment;
– reduction in hours;
– ineligibility for Medicare, Medicaid or CHIP;
– exhaustion of your COBRA coverage (if you were enrolled in COBRA through another
source); or
– termination of another employer's contribution toward the cost of coverage.
• gaining a dependent due to:
– marriage;***
– birth, adoption, placement for adoption/legal guardianship; or
– establishment of a qualified domestic partnership (including, for Kaiser Colorado only, the
establishment of a common-law marriage by qualified opposite-sex domestic partners, as
recognized by the state of Colorado).**
If you are pre-65 and not Medicare eligible, coverage for you and your dependents in the pre-65
option will be effective on the first day of the month following the date you experience a
qualifying Health Care Special Enrollment event and you contact the U.S. Bank Employee
Service Center to make your election. There are two exceptions: (1) If your Health Care Special
Enrollment occurs on the first day of the month and you contact the U.S. Bank Employee Service
Center on that day, your coverage becomes effective on that day; and (2) If you are adding a
newborn or newly adopted child (or a child newly placed with you for adoption), health care and
pharmacy care coverage for that dependent and for any other dependent you add due to that
event, will be retroactive to the date of the event. If coverage is retroactive, premiums will also
be retroactive.
If you and your eligible dependents are age 65 or older or pre-65 and Medicare eligible, your
coverage in the UnitedHealthcare or Medica Plan option is generally effective the first day of the
month after your application is received and processed, or the first of the month following the
date that you lose your other coverage, whichever is later.
* Loss of coverage due to non-payment of premiums or termination for cause, such as making fraudulent claims or
intentional misrepresentation, is not a qualifying event.
** Qualified domestic partners and dependents of domestic partners of West Employees who terminated before
January 1, 2002, are not eligible for coverage under the Program and may not be added to coverage due to a special
enrollment event.
***Under DOMA, marriage is defined as the legal union of a man and a woman.
Coverage Cancellation. You can cancel coverage for yourself and/or your dependents at any
time by calling the U.S. Bank Employee Service Center at 1-800-806-7009. If after electing
coverage at termination, you cancel or lose retiree health care coverage under the Program for
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Retiree Health Care SPD Effective January 1, 2012
any reason (including non-payment of premiums), you will not be able to re-enroll in the
Program unless you qualify for and complete a Health Care Special Enrollment. If you cancel or
lose retiree health care coverage, any covered dependents will also lose coverage, subject under
certain circumstances and rights to COBRA coverage.
Similarly, if you cancel coverage for an eligible dependent for any reason, that dependent will
not be able to re-enroll in the Program unless they qualify for and complete a Health Care
Special Enrollment.
If you and/or your dependents are enrolled in one of the pre-65 options or the Kaiser option, the
coverage cancellation effective date is the first of the month following the date that you contact
the U.S. Bank Employee Service Center to cancel coverage unless you contact the
U.S. Bank Employee Service Center on the first of the month, then your coverage will be
canceled on that day.
If you and your dependents are enrolled in the UnitedHealthcare or Medica Plan option, the
coverage cancellation effective date is the first of the month following the date that the U.S.
Bank Employee Service Center receives a written request to disenroll you and/or your
dependents from the UnitedHealthcare or Medica Plan option. This request must be signed and
dated by each member that wants to disenroll from the UnitedHealthcare or Medica Plan option.
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Eligibility and Enrollment Rules Section C
This eligibility and enrollment section only applies to:
• East Employees who retired prior to January 1, 2002;
• Employees formerly employed by Mercantile Bancorporation who retired before January 1,
2003;
• Former eligible Mercantile employees that went out on severance or LTD prior to January 1,
2003. (This includes eligible employees that went out on severance or LTD prior to January
1, 2003, and with severance or LTD ending after January 1, 2003.)
Retiree Eligibility
You are eligible to participate in the Program if you satisfied the age, service and any other
eligibility requirements in effect under the terms of the retiree health care plan applicable to you
at the time of your termination.
Employees formerly employed by Mercantile Bancorporation that went out on severance or LTD
prior to January 1, 2003 (this includes eligible employees that went out on severance or LTD
prior to January 1, 2003 and whose severance or LTD ended after January 1, 2003) did not need
to be enrolled in a U.S. Bank active employee health care option at the time of termination to be
eligible for this Program.
Dependent Eligibility
Refer to the materials from Kaiser for information about dependent eligibility under this
option.
“Eligible dependents” for the purposes of U.S. Bank benefits are listed below. You will need to
provide your dependent’s Social Security number (SSN) when adding or enrolling a dependent.
Refer to “Dependent Data Requirement” in this SPD for further information about this
requirement. U.S. Bank and its designated administrators may request proof of dependent
eligibility at any time. Failure to provide such proof may result in termination of coverage.
Your dependent(s) will be eligible to participate in the Program, if:
• your dependent was covered by a Firstar Group Health Insurance Plan benefit option at the
time of your termination (except dependents of employees formerly employed by Mercantile
Bancorporation who terminated before January 1, 2003 and dependents of former eligible
Mercantile employees that went out on severance or Long-Term Disability (LTD) prior to
January 1, 2003);
• you are eligible to participate in the Program and you enroll yourself and your eligible
dependent at the time of your termination;* and
• your dependent continues to satisfy one of the following requirements:
• Your spouse/domestic partner** (unless legally separated from you). Under the federal
Defense of Marriage Act (DOMA), a spouse is a husband or wife of opposite sex. A
common-law spouse may be covered only if you reside in a state that recognizes
common-law marriage and you meet the common-law requirements at the time you enroll
the dependent in coverage. To enroll a domestic partner in coverage, you must meet the
eligibility criteria defined under “Domestic Partner Eligibility” section in this SPD.
• You or your domestic partner’s children/grandchildren under age 26*** who are:
– your/your domestic partner’s biological children;
– your stepchildren;
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– your/your domestic partner’s foster children;
– children/grandchildren for whom you or your spouse/domestic partner have legal
guardianship****;
– children/grandchildren legally adopted by you or your spouse/domestic partner or
placed with you or your spouse/domestic partner for adoption****; and
– grandchildren who are eligible to be claimed as an exemption on you or your
spouse/domestic partner’s federal income tax return.
• Disabled children age 26 and older who otherwise meet the dependent children definition
may be covered as long as ALL of the following requirements are met:
– the child is severely disabled by prolonged physical or mental incapacity;
– the child became disabled prior to reaching age 26;
– the child was covered by the plan prior to reaching age 26, or, if older than age 26,
loses coverage under a parent’s/guardian’s plan. In the event of loss of coverage, proof of
prior coverage must be provided;
– the child remains unmarried and you/your domestic partner provide more than 50% of
his or her support because he or she is unable to earn a living; and
– disabled dependent status is approved by a medical Claims Administrator for U.S.
Bank.
* Eligible dependents of retirees of the former Mercantile only (at the time the retiree terminated employment) will
be allowed to enroll in the Program at a later date as long as the retiree enrolled at termination.
** Even though some localities may recognize same-sex marriages, the U.S. Bank Benefits Program is governed by
federal regulations which require that coverage for partners must be paid for on an after-tax basis, and the cost of
coverage be considered imputed income. Therefore, even in the event of marriage or civil union, if you are enrolling
your same-sex spouse you must designate him/her as a domestic partner.
*** For health care coverage, a newborn is not considered a dependent until birth.
**** Documentation of legal guardianship or adoption is required. Please call the U.S. Bank Employee Service
Center for instructions. The dependent cannot be added to your coverage until a copy of the applicable documents
are received and verified by the U.S. Bank Employee Service Center.
To have the disabled child considered for coverage, you and his or her doctor must complete an
application form for the child. The form is available from the applicable medical Claims
Administrator. To be considered, the form must be received by the medical Claims
Administrator no later than 30 days after the date the child turns age 26. See the “Important
Resources” section of this SPD for telephone numbers for the medical Claims Administrators. If
coverage for the child is approved, and the child is not considered permanently disabled,
periodically you will be asked to submit proof to the medical Claims Administrator that the child
continues to meet eligibility requirements. Failure to provide requested information may result in
loss of coverage for the dependent.
If your disabled dependent loses coverage under another health care plan, please contact the
U.S. Bank Employee Service Center for information regarding the procedure for applying for
coverage under the U.S. Bank Retiree Health Care Program.
Children who become disabled after age 26 are not eligible for coverage.
Ineligible Dependents. Ineligible dependents include but are not limited to the following:
• Dependents in the Military. Coverage is not available for any dependent on active duty in
the uniformed services or armed forces of any country.
• Dependent Parents. Coverage is not available for a retiree's or retiree's spouse's/domestic
partner’s parents.
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• Former Spouses/Domestic Partners. A spouse from whom you are divorced (even if the
divorce decree stipulates you will continue health care, pharmacy care, dental care or vision
care coverage for your ex-spouse) or legally separated, or a domestic partner or domestic
partner’s dependents if your domestic partnership has ended.
• Spouse/Domestic Partner of Adult Children/Grandchildren. Coverage is not available for
an adult child’s or grandchild’s spouse/domestic partner.
Enrolling ineligible dependents is a violation of company policy and will be treated accordingly.
If U.S. Bank determines that an ineligible dependent has been enrolled, coverage will be
cancelled retroactively. U.S. Bank reserves the right to recover any and all benefit payments
made for services received by ineligible dependents.
For more information about eligibility, enrollment and coverage for domestic partners and
dependents of domestic partners, see the “Domestic Partner Eligibility” section of this SPD.
Enrollment Rules
You may initiate your enrollment into the Program up to 90 days prior to your termination date
by contacting the U.S. Bank Employee Service Center at 1-800-806-7009 or online at
www.yourbenefitsresources.com/usbank. If you are eligible to participate in the Program when
you terminate from U.S. Bank and have not enrolled prior to your termination date, you will
receive enrollment materials that specify an enrollment deadline. You must enroll by the
deadline indicated on your election materials; otherwise you will not be covered by the Program.
Coverage Levels. For any of the health care options available to you, you can select from two
coverage levels:
• Individual (yourself — the retiree — only); or
• Family (you, and/or any eligible dependents as previously defined in this section).
Effective Date. If you elect coverage by your enrollment deadline, and are enrolling yourself
and/or your dependents in the Early Retiree Medical or Comprehensive option, coverage is
effective the first day of the month after the date your active employee health care ended or if
you are involuntarily terminated, coverage is effective the first day of the month after the date
your subsidized health care ended. For dependents covered with you as of the date of your
termination or the date your subsidized health care coverage ends, coverage will be effective the
same date as your coverage is effective, if you enroll them at the same time that you enroll. You
will be responsible for the retroactive premiums due for retiree coverage back to the effective
date of your retiree health care coverage.
If you elect coverage by your enrollment deadline, and are enrolling yourself and/or your
dependents in the UnitedHealthcare or Medica Plan option, coverage is generally effective the
first day of the month after your application(s) is received and processed. If you will experience
a lapse in coverage between your termination of employment and your effective date of
coverage, you must call the U.S. Bank Employee Service Center at 1-800-806-7009. You will be
responsible for the premiums due for retiree coverage back to the effective date of your retiree
health care coverage.
Deciding Between Retiree Health Care Coverage and COBRA Health Care Coverage.
Separate from the Program enrollment information, you and any other covered dependents will
also receive information on continuing the health care coverage you were enrolled in as an active
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Retiree Health Care SPD Effective January 1, 2012
employee under the provisions of COBRA. Each of your covered dependents will have an
independent right to decide whether to elect COBRA.
You and your covered dependents will need to decide whether to elect:
• Retiree Health Care Program coverage; or
• COBRA health care coverage.
By electing Retiree Health Care Program coverage, you will waive your COBRA health care
rights. You may, however, revoke such waiver at any time during the 60-day COBRA election
period.
If you elect COBRA health care rather than retiree health care coverage under the
Program, you will not have an option to enroll in the Program when you either stop or
exhaust your COBRA health care coverage.
It is important to carefully compare the benefits of COBRA health care versus retiree health care
coverage in making this decision. If you have questions about the two types of coverage, contact
the U.S. Bank Employee Service Center at 1-800-806-7009.
One Time Option to Enroll in Program. There is a single point of entry into the Program –
at the time of your termination. This means that if you do not enroll yourself and any
eligible dependents in the Program by the enrollment deadline stated on your enrollment
worksheet, you will not be able to enroll yourself and/or your dependents in retiree health
care coverage at any time in the future.
If, for example, at the time you terminate, you elect COBRA health care or coverage under a
spouse’s/domestic partner’s plan or a new employer’s plan, instead of coverage under the
Program, you will not be able to enroll in the Program at the time your COBRA health care
continuation period or other coverage ends. Similarly, you must enroll any eligible dependents in
the Program at the time of your termination to retain their coverage. Therefore, if you and/or a
dependent wants coverage under the Program at any point after your termination, you must
enroll when you terminate. You may, however, have the right to add new dependents gained
after your termination. Refer to the “New Dependents Gained After Your Termination” section
for more information.
However, eligible dependents of retirees of the former Mercantile (at the time the retiree
terminated employment) will be allowed to enroll in the Program at a later date (as long as the
retiree enrolled at the time they terminated). The eligible dependent must qualify for and
complete the Mercantile Health Care Special Enrollment. To request a Mercantile Health Care
Special Enrollment, call the U.S. Bank Employee Service Center at 1-800-806-7009 and speak to
a representative. Eligible dependents are only allowed one enrollment into the Program.
Therefore if the eligible dependent enrolls in coverage and subsequently cancels coverage, they
will not be allowed to enroll in the Program at a later date.
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Retiree Health Care SPD Effective January 1, 2012
New Dependents Gained After Your Termination. If you gain a dependent after you terminate
due to marriage, commencement of a domestic partnership, birth, adoption or commencement of
a legal guardianship, your new dependent may be eligible for coverage under the Program if the
following requirements are met:
• You must enroll your new dependent within 60 days of the date they first become your
dependent after termination; and
• Your new dependent continues to satisfy the requirements of an "eligible dependent,” as
defined in the “Dependent Eligibility” section.
If, however, one of your current dependents later gains eligibility due to a change in the
eligibility requirements, you will not be able to enroll that dependent in the Program.
To enroll a new dependent, call the U.S. Bank Employee Service Center at 1-800-806-7009 and
speak to a representative. If your new dependent is a domestic partner or dependent of a
domestic partner, see the “Domestic Partner Eligibility” section in this SPD.
If you are enrolling your dependent(s) in the Early Retiree Medical or Comprehensive option,
your benefit changes will be effective on the first day of the month following the date you
experience a qualifying new dependent enrollment event and contact the U.S. Bank Employee
Service Center to make your election unless:
• You are adding a newborn or newly adopted child (or a child newly placed with you for
adoption). If you are adding a newborn or newly adopted/placed for adoption child,
health care coverage for that dependent will be retroactive to the date of the event. If
coverage is retroactive, premiums will also be retroactive; or
• If your new dependent enrollment event occurs on the first of the month and you contact
the U.S. Bank Employee Service Center on that day, your coverage will become effective
on that day.
If you are enrolling your dependent(s) in the UnitedHealthcare or Medica Plan option, coverage
is generally effective the first day of the month after your application is received and processed,
or the first of the month following the date you experience a qualifying new dependent
enrollment event and contact the U.S. Bank Employee Service Center to make your election,
whichever is later.
Coverage Cancellation. You can cancel coverage for yourself and/or your dependents at any
time by calling the U.S. Bank Employee Service Center at 1-800-806-7009. If after electing
coverage at termination, you cancel or lose retiree health care coverage under the Program for
any reason (including non-payment of premiums), you will not be able to re-enroll in the
Program. If you cancel or lose retiree health care coverage, any covered dependents will also
lose coverage, subject under certain circumstances and rights to COBRA coverage.
Similarly, if you cancel coverage for an eligible dependent for any reason, that dependent will
not be able to re-enroll in the Program.
If you and/or your dependents are enrolled in the Early Retiree Medical, Comprehensive or the
Kaiser option, the coverage cancellation effective date is the first of the month following the date
that you contact the U.S. Bank Employee Service Center to cancel coverage unless you contact
the U.S. Bank Employee Service Center on the first of the month, then your coverage will be
canceled on that day.
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Retiree Health Care SPD Effective January 1, 2012
If you and your dependents are enrolled in the UnitedHealthcare or Medica Plan option, the
coverage cancellation effective date is the first of the month following the date that the U.S.
Bank Employee Service Center receives a written request to disenroll you and/or your
dependents from the UnitedHealthcare or Medica Plan option. This request must be signed and
dated by each member that wants to disenroll from the UnitedHealthcare or Medica Plan option.
Your Benefit Option as of August 1, 2002. If you were an East retiree already participating in
the Program and under age 65 as of August 1, 2002, you were automatically enrolled in the
Standard Managed Care option, unless no network was available in your region, in which case,
you were enrolled in the Comprehensive option. If you were over age 65 as of August 1, 2002,
you were automatically enrolled in the Comprehensive option. The Low option was not available
to East Employees who terminated before August 1, 2002.
If you are under age 65 and not Medicare eligible, you may not change your benefit option,
unless you are enrolled in the Comprehensive option, and access to the BCBS BlueCard PPO
network subsequently becomes available or you move to a region with access to the BCBS
BlueCard PPO network. Under these circumstances, you will automatically be moved to the
Early Retiree Medical option.
When you or your covered dependent becomes eligible for Medicare, your Program option may
change. For more information, refer to the “Medicare Eligible Retirees and Dependents Turning
Age 65” section of this SPD.
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